{ "hospital_name": "Northwestern Medicine Delnor Hospital", "last_updated_on": "2026-04-01", "version": "3.0.0", "location_name": [ "Northwestern Medicine Delnor Hospital" ], "hospital_address": [ "300 Randall Rd., Geneva, IL 60134" ], "license_information": { "license_number": "0005736", "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": [ "1407859655" ], "standard_charge_information": [ { "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": 4.63, "maximum": 28.42, "setting": "outpatient", "gross_charge": 28.42, "discounted_cash": 19.89, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 17.62, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 17.62, "10th_percentile": 17.62, "90th_percentile": 17.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 17.62, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 17.62, "10th_percentile": 17.62, "90th_percentile": 17.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 8.2, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.2, "10th_percentile": 8.2, "90th_percentile": 8.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 19.81, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19.81, "10th_percentile": 19.81, "90th_percentile": 19.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 8.04, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.04, "10th_percentile": 8.04, "90th_percentile": 8.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 15.89, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15.89, "10th_percentile": 15.89, "90th_percentile": 15.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 10.24, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.24, "10th_percentile": 10.24, "90th_percentile": 10.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 7.96, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.96, "10th_percentile": 7.96, "90th_percentile": 7.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 25.58, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 25.58, "10th_percentile": 25.58, "90th_percentile": 25.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 25.58, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 25.58, "10th_percentile": 25.58, "90th_percentile": 25.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 14.21, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 14.21, "10th_percentile": 14.21, "90th_percentile": 14.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 18.47, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 18.47, "10th_percentile": 18.47, "90th_percentile": 18.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 21.32, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% 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; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 24.16, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 24.16, "10th_percentile": 24.16, "90th_percentile": 24.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 19.3, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19.3, "10th_percentile": 19.3, "90th_percentile": 19.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 28.42, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 28.42, "10th_percentile": 28.42, "90th_percentile": 28.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 22.74, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 22.74, "10th_percentile": 22.74, "90th_percentile": 22.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 13.47, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13.47, "10th_percentile": 13.47, "90th_percentile": 13.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 14.98, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14.98, "10th_percentile": 14.98, "90th_percentile": 14.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 28.42, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 28.42, "10th_percentile": 28.42, "90th_percentile": 28.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 18.25, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 18.25, "10th_percentile": 18.25, "90th_percentile": 18.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 21.32, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 21.32, "10th_percentile": 21.32, "90th_percentile": 21.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 6.2, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.2, "10th_percentile": 6.2, "90th_percentile": 6.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 22.74, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 22.74, "10th_percentile": 22.74, "90th_percentile": 22.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 13.93, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13.93, "10th_percentile": 13.93, "90th_percentile": 13.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 14.21, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14.21, "10th_percentile": 14.21, "90th_percentile": 14.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 19.81, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19.81, "10th_percentile": 19.81, "90th_percentile": 19.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 19.61, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 19.61, "10th_percentile": 19.61, "90th_percentile": 19.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 4.63, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 4.63, "10th_percentile": 4.63, "90th_percentile": 4.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 10.24, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.24, "10th_percentile": 10.24, "90th_percentile": 10.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 17.9, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 17.9, "10th_percentile": 17.9, "90th_percentile": 17.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 28.42, "10th_percentile": 28.42, "90th_percentile": 28.42, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 28.42, "10th_percentile": 28.42, "90th_percentile": 28.42, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 28.42, "10th_percentile": 28.42, "90th_percentile": 28.42, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 28.42, "10th_percentile": 28.42, "90th_percentile": 28.42, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 28.42, "10th_percentile": 28.42, "90th_percentile": 28.42, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 28.42, "10th_percentile": 28.42, "90th_percentile": 28.42, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 28.42, "10th_percentile": 28.42, "90th_percentile": 28.42, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 28.42, "10th_percentile": 28.42, "90th_percentile": 28.42, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 28.42, "10th_percentile": 28.42, "90th_percentile": 28.42, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 28.42, "10th_percentile": 28.42, "90th_percentile": 28.42, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 28.42, "10th_percentile": 28.42, "90th_percentile": 28.42, "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": 111.93, "maximum": 751.2, "setting": "outpatient", "gross_charge": 751.2, "discounted_cash": 525.84, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 465.74, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 465.74, "10th_percentile": 465.74, "90th_percentile": 465.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 751.2, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 751.2, "10th_percentile": 751.2, "90th_percentile": 751.2, "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": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 111.93, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 111.93, "10th_percentile": 111.93, "90th_percentile": 111.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 111.93, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 111.93, "10th_percentile": 111.93, "90th_percentile": 111.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 419.92, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 419.92, "10th_percentile": 419.92, "90th_percentile": 419.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 135.22, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 135.22, "10th_percentile": 135.22, "90th_percentile": 135.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 523.74, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 523.74, "10th_percentile": 523.74, "90th_percentile": 523.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 175.03, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 175.03, "10th_percentile": 175.03, "90th_percentile": 175.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 510.06, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 510.06, "10th_percentile": 510.06, "90th_percentile": 510.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 122.45, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 122.45, "10th_percentile": 122.45, "90th_percentile": 122.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 523.74, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 523.74, "10th_percentile": 523.74, "90th_percentile": 523.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 175.03, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 175.03, "10th_percentile": 175.03, "90th_percentile": 175.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 676.08, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 676.08, "10th_percentile": 676.08, "90th_percentile": 676.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 375.6, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 375.6, "10th_percentile": 375.6, "90th_percentile": 375.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 163.76, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 163.76, "10th_percentile": 163.76, "90th_percentile": 163.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 600.96, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 600.96, "10th_percentile": 600.96, "90th_percentile": 600.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 368.09, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 368.09, "10th_percentile": 368.09, "90th_percentile": 368.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 600.96, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 600.96, "10th_percentile": 600.96, "90th_percentile": 600.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 465.74, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 465.74, "10th_percentile": 465.74, "90th_percentile": 465.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 518.33, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 518.33, "10th_percentile": 518.33, "90th_percentile": 518.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 563.4, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 563.4, "10th_percentile": 563.4, "90th_percentile": 563.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 375.6, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 375.6, "10th_percentile": 375.6, "90th_percentile": 375.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 488.28, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 488.28, "10th_percentile": 488.28, "90th_percentile": 488.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 638.52, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 638.52, "10th_percentile": 638.52, "90th_percentile": 638.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 473.26, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 473.26, "10th_percentile": 473.26, "90th_percentile": 473.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 676.08, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 676.08, "10th_percentile": 676.08, "90th_percentile": 676.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 563.4, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 563.4, "10th_percentile": 563.4, "90th_percentile": 563.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 482.5, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 482.5, "10th_percentile": 482.5, "90th_percentile": 482.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 356.07, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 356.07, "10th_percentile": 356.07, "90th_percentile": 356.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 395.88, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 395.88, "10th_percentile": 395.88, "90th_percentile": 395.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 751.2, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 751.2, "10th_percentile": 751.2, "90th_percentile": 751.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $751.20 @ 12.5% = $93.90 due to $0.00 Claim Price", "median_amount": 93.9, "10th_percentile": 93.9, "90th_percentile": 93.9, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $751.20 @ 12.5% = $93.90 due to $0.00 Claim Price" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $751.20 @ 6.8% = $51.08 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": 51.08, "10th_percentile": 51.08, "90th_percentile": 51.08, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $751.20 @ 6.8% = $51.08 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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $751.20 @ 6.8% = $51.08 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": 51.08, "10th_percentile": 51.08, "90th_percentile": 51.08, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $751.20 @ 6.8% = $51.08 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $751.20 @ 6.8% = $51.08 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": 51.08, "10th_percentile": 51.08, "90th_percentile": 51.08, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $751.20 @ 6.8% = $51.08 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": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 751.2, "10th_percentile": 751.2, "90th_percentile": 751.2, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 751.2, "10th_percentile": 751.2, "90th_percentile": 751.2, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 751.2, "10th_percentile": 751.2, "90th_percentile": 751.2, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 751.2, "10th_percentile": 751.2, "90th_percentile": 751.2, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 751.2, "10th_percentile": 751.2, "90th_percentile": 751.2, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 751.2, "10th_percentile": 751.2, "90th_percentile": 751.2, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 751.2, "10th_percentile": 751.2, "90th_percentile": 751.2, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "ACUTE MAJOR EYE INFECTIONS WITH CC/MCC", "code_information": [ { "code": "121", "type": "MS-DRG" } ], "standard_charges": [ { "minimum": 8277.85, "maximum": 18132.36, "setting": "inpatient", "gross_charge": 30722.0, "discounted_cash": 21505.4, "payers_information": [ { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.786913007; Using historical claim(s); Scope: All Financial Classes; Cases: 1; Inpatient (Non Covered - Verify Coverage); 100% Billed", "median_amount": 26337.0, "10th_percentile": 26337.0, "90th_percentile": 26337.0, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Additional drugs, labs, and radiology services can be included in reimbursement.", "median_amount": 23041.5, "10th_percentile": 23041.5, "90th_percentile": 23041.5, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_percentage": 49.0, "standard_charge_algorithm": "Re-evaluated: HLB.786913007; Using historical claim(s); Scope: All Financial Classes; Cases: 1; IP Services. ADP RATE (for patient estimates only); 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15385.6, "10th_percentile": 15385.6, "90th_percentile": 15385.6, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_percentage": 90.0, "standard_charge_algorithm": "Additional drugs, labs, and radiology services can be included in reimbursement.", "median_amount": 27649.81, "10th_percentile": 27649.81, "90th_percentile": 27649.81, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_percentage": 67.8, "standard_charge_algorithm": "Re-evaluated: HLB.786913007; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All Inpatient Services; 67.8% Billed", "median_amount": 20887.22, "10th_percentile": 20887.22, "90th_percentile": 20887.22, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_percentage": 16.3, "standard_charge_algorithm": "Additional drugs, labs, and radiology services can be included in reimbursement.", "median_amount": 5007.71, "10th_percentile": 5007.71, "90th_percentile": 5007.71, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Additional drugs, labs, and radiology services can be included in reimbursement.", "median_amount": 24577.6, "10th_percentile": 24577.6, "90th_percentile": 24577.6, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Re-evaluated: HLB.786913007; Using historical claim(s); Scope: All Financial Classes; Cases: 1; OP DEFAULT; 80% Billed", "median_amount": 3847.2, "10th_percentile": 3847.2, "90th_percentile": 3847.2, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 18132.36, "standard_charge_algorithm": "Re-evaluated: HLB.786913007; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1633, Rate: 15,587.00, and; Pricing Extension - NM HB XR PRC - DCH 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": 19267.57, "10th_percentile": 19267.57, "90th_percentile": 19267.57, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 8749.18, "standard_charge_algorithm": "Re-evaluated: HLB.786913007; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1633, Rate: 7,521.00, and; Pricing Extension - NM HB XR PRC - DCH 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": 12102.01, "10th_percentile": 12102.01, "90th_percentile": 12102.01, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 10447.6, "standard_charge_algorithm": "Re-evaluated: HLB.786913007; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1633, Rate: 8,981.00, and; Pricing Extension - NM HB XR PRC - DCH 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": 11352.87, "10th_percentile": 11352.87, "90th_percentile": 11352.87, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 8634.01, "standard_charge_algorithm": "Re-evaluated: HLB.786913007; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1633, Rate: 7,422.00, and; Pricing Extension - NM HB XR PRC - DCH BCBS CHOICE SELECT CASE RATE W/OUTLIER S*", "median_amount": 9512.65, "10th_percentile": 9512.65, "90th_percentile": 9512.65, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 8807.34, "standard_charge_algorithm": "Re-evaluated: HLB.786913007; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1633, Rate: 7,571.00, and; Pricing Extension - NM HB XR PRC - DCH 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": 9695.66, "10th_percentile": 9695.66, "90th_percentile": 9695.66, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 18132.36, "standard_charge_algorithm": "Re-evaluated: HLB.786913007; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1633, Rate: 15,587.00, and; Pricing Extension - NM HB XR PRC - DCH 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": 19267.57, "10th_percentile": 19267.57, "90th_percentile": 19267.57, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 8749.18, "standard_charge_algorithm": "Re-evaluated: HLB.786913007; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1633, Rate: 7,521.00, and; Pricing Extension - NM HB XR PRC - DCH 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": 12102.01, "10th_percentile": 12102.01, "90th_percentile": 12102.01, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_dollar": 8277.85, "standard_charge_algorithm": "Re-evaluated: HLB.786913007; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All DRGs (Plans excl O-IME); FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.16, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALCULATION EXCL O-IME; Note: Base payment: $8,991.57; Total: $8,991.57", "median_amount": 9107.62, "10th_percentile": 9107.62, "90th_percentile": 9107.62, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.786913007; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All DRGs (Plans excl O-IME); FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.16, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALCULATION EXCL O-IME; Note: Base payment: $8,991.57; Total: $8,991.57" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 8277.85, "standard_charge_algorithm": "Re-evaluated: HLB.786913007; Using historical claim(s); Scope: All Financial Classes; Cases: 1; 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: $8,991.57; Total: $8,991.57 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9107.62, "10th_percentile": 9107.62, "90th_percentile": 9107.62, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.786913007; Using historical claim(s); Scope: All Financial Classes; Cases: 1; 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: $8,991.57; Total: $8,991.57 Paid at contractual rate, which is the lesser of 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": "DCH HUMANA MEDICARE ADVT", "standard_charge_dollar": 8277.85, "standard_charge_algorithm": "Re-evaluated: HLB.786913007; Using historical claim(s); Scope: All Financial Classes; Cases: 1; 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: $8,935.87; Total: $8,935.87 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9051.92, "10th_percentile": 9051.92, "90th_percentile": 9051.92, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.786913007; Using historical claim(s); Scope: All Financial Classes; Cases: 1; 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: $8,935.87; Total: $8,935.87 Paid at contractual rate, which is the lesser 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": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_dollar": 8277.85, "standard_charge_algorithm": "Re-evaluated: HLB.786913007; Using historical claim(s); Scope: All Financial Classes; Cases: 1; 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: $8,991.57; Percentage applied: 97.00%; Total: $8,721.82 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8829.75, "10th_percentile": 8829.75, "90th_percentile": 8829.75, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.786913007; Using historical claim(s); Scope: All Financial Classes; Cases: 1; 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: $8,991.57; Percentage applied: 97.00%; Total: $8,721.82 Paid at contractual rate, which is the lesser 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": "DCH HFN PPO", "standard_charge_percentage": 85.0, "standard_charge_algorithm": "Additional drugs, labs, and radiology services can be included in reimbursement.", "median_amount": 26113.7, "10th_percentile": 26113.7, "90th_percentile": 26113.7, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Additional drugs, labs, and radiology services can be included in reimbursement.", "median_amount": 15361.01, "10th_percentile": 15361.01, "90th_percentile": 15361.01, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_percentage": 65.0, "standard_charge_algorithm": "Additional drugs, labs, and radiology services can be included in reimbursement.", "median_amount": 19969.3, "10th_percentile": 19969.3, "90th_percentile": 19969.3, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Re-evaluated: HLB.786913007; Using historical claim(s); Scope: All Financial Classes; Cases: 1; Inpatient Services; 63% Billed", "median_amount": 19354.86, "10th_percentile": 19354.86, "90th_percentile": 19354.86, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_percentage": 90.0, "standard_charge_algorithm": "Additional drugs, labs, and radiology services can be included in reimbursement.", "median_amount": 27649.81, "10th_percentile": 27649.81, "90th_percentile": 27649.81, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.786913007; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; 100% Billed", "median_amount": 30722.0, "10th_percentile": 30722.0, "90th_percentile": 30722.0, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.786913007; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services - OON; 100% Billed", "median_amount": 28207.0, "10th_percentile": 28207.0, "90th_percentile": 28207.0, "count": "1 through 10", "methodology": "percent of total billed charges" } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC", "code_information": [ { "code": "283", "type": "MS-DRG" } ], "standard_charges": [ { "minimum": 14095.04, "maximum": 30874.73, "setting": "inpatient", "gross_charge": 45785.5, "discounted_cash": 32049.85, "payers_information": [ { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_percentage": 65.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 29760.58, "10th_percentile": 29760.58, "90th_percentile": 29760.58, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 34339.12, "10th_percentile": 34339.12, "90th_percentile": 34339.12, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH 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": 22892.8, "10th_percentile": 22892.8, "90th_percentile": 22892.8, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_percentage": 85.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 38917.7, "10th_percentile": 38917.7, "90th_percentile": 38917.7, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Re-evaluated: HLB.828984030; Using historical claim(s); Scope: All Financial Classes; Cases: 7; Inpatient Services; 63% Billed", "median_amount": 28844.86, "10th_percentile": 28844.86, "90th_percentile": 28844.86, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_percentage": 67.8, "standard_charge_algorithm": "Re-evaluated: HLB.828984030; Using historical claim(s); Scope: All Financial Classes; Cases: 7; All Inpatient Services; 67.8% Billed", "median_amount": 31042.56, "10th_percentile": 31042.56, "90th_percentile": 31042.56, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH 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": 36628.38, "10th_percentile": 36628.38, "90th_percentile": 36628.38, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_percentage": 16.3, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 7463.05, "10th_percentile": 7463.05, "90th_percentile": 7463.05, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_percentage": 49.0, "standard_charge_algorithm": "Re-evaluated: HLB.828984030; Using historical claim(s); Scope: All Financial Classes; Cases: 7; IP Services. ADP RATE (for patient estimates only); 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 22434.89, "10th_percentile": 22434.89, "90th_percentile": 22434.89, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_percentage": 90.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 41206.95, "10th_percentile": 41206.95, "90th_percentile": 41206.95, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_percentage": 90.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 41206.95, "10th_percentile": 41206.95, "90th_percentile": 41206.95, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.828984030; Using historical claim(s); Scope: All Financial Classes; Cases: 7; All IP Services; 100% Billed", "median_amount": 45785.49, "10th_percentile": 45785.49, "90th_percentile": 45785.49, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.828984030; Using historical claim(s); Scope: All Financial Classes; Cases: 7; All IP Services - OON; 100% Billed", "median_amount": 45785.49, "10th_percentile": 45785.49, "90th_percentile": 45785.49, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.828984030; Using historical claim(s); Scope: All Financial Classes; Cases: 7; Inpatient (Non Covered - Verify Coverage); 100% Billed", "median_amount": 45785.49, "10th_percentile": 45785.49, "90th_percentile": 45785.49, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 30874.73, "standard_charge_algorithm": "Re-evaluated: HLB.828984030; Using historical claim(s); Scope: All Financial Classes; Cases: 7; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.9808, Rate: 15,587.00, and; Pricing Extension - NM HB XR PRC - DCH 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": 30874.73, "10th_percentile": 30874.73, "90th_percentile": 30874.73, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 14897.6, "standard_charge_algorithm": "Re-evaluated: HLB.828984030; Using historical claim(s); Scope: All Financial Classes; Cases: 7; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.9808, Rate: 7,521.00, and; Pricing Extension - NM HB XR PRC - DCH 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": 14897.6, "10th_percentile": 14897.6, "90th_percentile": 14897.6, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 30874.73, "standard_charge_algorithm": "Re-evaluated: HLB.828984030; Using historical claim(s); Scope: All Financial Classes; Cases: 7; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.9808, Rate: 15,587.00, and; Pricing Extension - NM HB XR PRC - DCH 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": 30874.73, "10th_percentile": 30874.73, "90th_percentile": 30874.73, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 17789.56, "standard_charge_algorithm": "Re-evaluated: HLB.828984030; Using historical claim(s); Scope: All Financial Classes; Cases: 7; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.9808, Rate: 8,981.00, and; Pricing Extension - NM HB XR PRC - DCH 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": 17789.56, "10th_percentile": 17789.56, "90th_percentile": 17789.56, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 14701.5, "standard_charge_algorithm": "Re-evaluated: HLB.828984030; Using historical claim(s); Scope: All Financial Classes; Cases: 7; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.9808, Rate: 7,422.00, and; Pricing Extension - NM HB XR PRC - DCH BCBS CHOICE SELECT CASE RATE W/OUTLIER S*", "median_amount": 14701.5, "10th_percentile": 14701.5, "90th_percentile": 14701.5, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 14996.64, "standard_charge_algorithm": "Re-evaluated: HLB.828984030; Using historical claim(s); Scope: All Financial Classes; Cases: 7; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.9808, Rate: 7,571.00, and; Pricing Extension - NM HB XR PRC - DCH 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": 14996.64, "10th_percentile": 14996.64, "90th_percentile": 14996.64, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 14897.6, "standard_charge_algorithm": "Re-evaluated: HLB.828984030; Using historical claim(s); Scope: All Financial Classes; Cases: 7; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.9808, Rate: 7,521.00, and; Pricing Extension - NM HB XR PRC - DCH 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": 14897.6, "10th_percentile": 14897.6, "90th_percentile": 14897.6, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_dollar": 14095.04, "standard_charge_algorithm": "Re-evaluated: HLB.828984030; Using historical claim(s); Scope: All Financial Classes; Cases: 7; All DRGs (Plans excl O-IME); FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.98, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALCULATION EXCL O-IME; Note: Base payment: $15,310.34; Total: $15,310.34", "median_amount": 15310.34, "10th_percentile": 15310.34, "90th_percentile": 15310.34, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.828984030; Using historical claim(s); Scope: All Financial Classes; Cases: 7; All DRGs (Plans excl O-IME); FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.98, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALCULATION EXCL O-IME; Note: Base payment: $15,310.34; Total: $15,310.34" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "DCH HUMANA MEDICARE ADVT", "standard_charge_dollar": 14095.04, "standard_charge_algorithm": "Re-evaluated: HLB.828984030; 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: $15,215.49; Total: $15,215.49 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15215.49, "10th_percentile": 15215.49, "90th_percentile": 15215.49, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.828984030; 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: $15,215.49; Total: $15,215.49 Paid at contractual rate, which is the lesser 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": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_dollar": 14095.04, "standard_charge_algorithm": "Re-evaluated: HLB.828984030; 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: $15,310.34; Percentage applied: 97.00%; Total: $14,851.03 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14851.03, "10th_percentile": 14851.03, "90th_percentile": 14851.03, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.828984030; 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: $15,310.34; Percentage applied: 97.00%; Total: $14,851.03 Paid at contractual rate, which is the lesser of contractual and 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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 14095.04, "standard_charge_algorithm": "Re-evaluated: HLB.828984030; 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: $15,310.34; Total: $15,310.34 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15310.34, "10th_percentile": 15310.34, "90th_percentile": 15310.34, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.828984030; 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: $15,310.34; Total: $15,310.34 Paid at contractual rate, which is 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 800 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-8972", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "50268-0062-15", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.79, "maximum": 11.0, "setting": "outpatient", "gross_charge": 11.0, "discounted_cash": 7.7, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 6.15, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.15, "10th_percentile": 6.15, "90th_percentile": 6.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 3.96, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.96, "10th_percentile": 3.96, "90th_percentile": 3.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 3.11, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.11, "10th_percentile": 3.11, "90th_percentile": 3.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 3.17, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.17, "10th_percentile": 3.17, "90th_percentile": 3.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 7.67, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.67, "10th_percentile": 7.67, "90th_percentile": 7.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 6.82, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.82, "10th_percentile": 6.82, "90th_percentile": 6.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 9.9, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 9.9, "10th_percentile": 9.9, "90th_percentile": 9.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 9.35, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 9.35, "10th_percentile": 9.35, "90th_percentile": 9.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 8.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 8.25, "10th_percentile": 8.25, "90th_percentile": 8.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 7.15, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 7.15, "10th_percentile": 7.15, "90th_percentile": 7.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 5.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 5.5, "10th_percentile": 5.5, "90th_percentile": 5.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 5.39, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.39, "10th_percentile": 5.39, "90th_percentile": 5.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 5.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.5, "10th_percentile": 5.5, "90th_percentile": 5.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 11.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 11.0, "10th_percentile": 11.0, "90th_percentile": 11.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 8.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 8.8, "10th_percentile": 8.8, "90th_percentile": 8.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 5.8, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.8, "10th_percentile": 5.8, "90th_percentile": 5.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 5.21, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.21, "10th_percentile": 5.21, "90th_percentile": 5.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 6.93, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 6.93, "10th_percentile": 6.93, "90th_percentile": 6.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 7.59, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 7.59, "10th_percentile": 7.59, "90th_percentile": 7.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 7.07, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 7.07, "10th_percentile": 7.07, "90th_percentile": 7.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - 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": "DCH PHCS", "standard_charge_dollar": 8.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 8.25, "10th_percentile": 8.25, "90th_percentile": 8.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 2.4, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.4, "10th_percentile": 2.4, "90th_percentile": 2.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 11.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 11.0, "10th_percentile": 11.0, "90th_percentile": 11.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 8.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 8.8, "10th_percentile": 8.8, "90th_percentile": 8.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 11.0, "10th_percentile": 11.0, "90th_percentile": 11.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11.0, "10th_percentile": 11.0, "90th_percentile": 11.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11.0, "10th_percentile": 11.0, "90th_percentile": 11.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11.0, "10th_percentile": 11.0, "90th_percentile": 11.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11.0, "10th_percentile": 11.0, "90th_percentile": 11.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11.0, "10th_percentile": 11.0, "90th_percentile": 11.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11.0, "10th_percentile": 11.0, "90th_percentile": 11.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11.0, "10th_percentile": 11.0, "90th_percentile": 11.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 3.08, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.08, "10th_percentile": 3.08, "90th_percentile": 3.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11.0, "10th_percentile": 11.0, "90th_percentile": 11.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11.0, "10th_percentile": 11.0, "90th_percentile": 11.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11.0, "10th_percentile": 11.0, "90th_percentile": 11.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 6.82, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.82, "10th_percentile": 6.82, "90th_percentile": 6.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 9.9, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 9.9, "10th_percentile": 9.9, "90th_percentile": 9.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 7.47, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 7.67, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.67, "10th_percentile": 7.67, "90th_percentile": 7.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 3.96, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.96, "10th_percentile": 3.96, "90th_percentile": 3.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 1.79, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 1.79, "10th_percentile": 1.79, "90th_percentile": 1.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" } ] } ] }, { "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": 10.84, "maximum": 66.5, "setting": "outpatient", "gross_charge": 66.5, "discounted_cash": 46.55, "payers_information": [ { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 66.5, "10th_percentile": 66.5, "90th_percentile": 66.5, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 66.5, "10th_percentile": 66.5, "90th_percentile": 66.5, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 66.5, "10th_percentile": 66.5, "90th_percentile": 66.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 66.5, "10th_percentile": 66.5, "90th_percentile": 66.5, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 66.5, "10th_percentile": 66.5, "90th_percentile": 66.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 66.5, "10th_percentile": 66.5, "90th_percentile": 66.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 66.5, "10th_percentile": 66.5, "90th_percentile": 66.5, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 66.5, "10th_percentile": 66.5, "90th_percentile": 66.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 66.5, "10th_percentile": 66.5, "90th_percentile": 66.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 66.5, "10th_percentile": 66.5, "90th_percentile": 66.5, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 66.5, "10th_percentile": 66.5, "90th_percentile": 66.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 37.17, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 37.17, "10th_percentile": 37.17, "90th_percentile": 37.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 46.36, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 46.36, "10th_percentile": 46.36, "90th_percentile": 46.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 59.85, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 59.85, "10th_percentile": 59.85, "90th_percentile": 59.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 59.85, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 59.85, "10th_percentile": 59.85, "90th_percentile": 59.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 43.23, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 43.23, "10th_percentile": 43.23, "90th_percentile": 43.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 49.88, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 49.88, "10th_percentile": 49.88, "90th_percentile": 49.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 33.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 33.25, "10th_percentile": 33.25, "90th_percentile": 33.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 56.53, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 56.53, "10th_percentile": 56.53, "90th_percentile": 56.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 46.36, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 46.36, "10th_percentile": 46.36, "90th_percentile": 46.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 45.89, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 45.89, "10th_percentile": 45.89, "90th_percentile": 45.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 53.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 53.2, "10th_percentile": 53.2, "90th_percentile": 53.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 33.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 33.25, "10th_percentile": 33.25, "90th_percentile": 33.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 49.88, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 49.88, "10th_percentile": 49.88, "90th_percentile": 49.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 41.9, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 41.9, "10th_percentile": 41.9, "90th_percentile": 41.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 53.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 53.2, "10th_percentile": 53.2, "90th_percentile": 53.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 10.84, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 10.84, "10th_percentile": 10.84, "90th_percentile": 10.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 66.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 66.5, "10th_percentile": 66.5, "90th_percentile": 66.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 66.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 66.5, "10th_percentile": 66.5, "90th_percentile": 66.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "ADAPTA S PACEMAKER", "code_information": [ { "code": "SUP-117685", "type": "CDM" }, { "code": "C1785", "type": "HCPCS" }, { "code": "0275", "type": "RC" } ], "standard_charges": [ { "minimum": 5435.26, "maximum": 36999.7, "setting": "outpatient", "gross_charge": 36999.7, "discounted_cash": 25899.79, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 36999.7, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 36999.7, "10th_percentile": 36999.7, "90th_percentile": 36999.7, "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": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 5512.96, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5512.96, "10th_percentile": 5512.96, "90th_percentile": 5512.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 6659.95, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6659.95, "10th_percentile": 6659.95, "90th_percentile": 6659.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 5512.96, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5512.96, "10th_percentile": 5512.96, "90th_percentile": 5512.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 25796.19, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 25796.19, "10th_percentile": 25796.19, "90th_percentile": 25796.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 20682.83, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20682.83, "10th_percentile": 20682.83, "90th_percentile": 20682.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 8620.93, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 8620.93, "10th_percentile": 8620.93, "90th_percentile": 8620.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 5435.26, "standard_charge_percentage": 14.69, "standard_charge_algorithm": "Implant/Prosthetic Rev Code 275; 14.69% Billed", "median_amount": 5435.26, "10th_percentile": 5435.26, "90th_percentile": 5435.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Implant/Prosthetic Rev Code 275; 14.69% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 5435.26, "standard_charge_percentage": 14.69, "standard_charge_algorithm": "Implant/Prosthetic Rev Code 275; 14.69% Billed", "median_amount": 5435.26, "10th_percentile": 5435.26, "90th_percentile": 5435.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Implant/Prosthetic Rev Code 275; 14.69% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 6030.95, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 6030.95, "10th_percentile": 6030.95, "90th_percentile": 6030.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 25796.19, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 25796.19, "10th_percentile": 25796.19, "90th_percentile": 25796.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 8620.93, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 8620.93, "10th_percentile": 8620.93, "90th_percentile": 8620.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 33299.73, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 33299.73, "10th_percentile": 33299.73, "90th_percentile": 33299.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 18499.85, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 18499.85, "10th_percentile": 18499.85, "90th_percentile": 18499.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 8065.93, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8065.93, "10th_percentile": 8065.93, "90th_percentile": 8065.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 29599.76, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 29599.76, "10th_percentile": 29599.76, "90th_percentile": 29599.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 18129.85, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 18129.85, "10th_percentile": 18129.85, "90th_percentile": 18129.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 29599.76, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 29599.76, "10th_percentile": 29599.76, "90th_percentile": 29599.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 5435.26, "standard_charge_percentage": 14.69, "standard_charge_algorithm": "Implant/Prosthetic Rev Code 275; 14.69% Billed", "median_amount": 5435.26, "10th_percentile": 5435.26, "90th_percentile": 5435.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Implant/Prosthetic Rev Code 275; 14.69% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 25529.79, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 25529.79, "10th_percentile": 25529.79, "90th_percentile": 25529.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 27749.78, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 27749.78, "10th_percentile": 27749.78, "90th_percentile": 27749.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 18499.85, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 18499.85, "10th_percentile": 18499.85, "90th_percentile": 18499.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 24049.81, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 24049.81, "10th_percentile": 24049.81, "90th_percentile": 24049.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 31449.75, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 31449.75, "10th_percentile": 31449.75, "90th_percentile": 31449.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 23309.81, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 23309.81, "10th_percentile": 23309.81, "90th_percentile": 23309.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 33299.73, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 33299.73, "10th_percentile": 33299.73, "90th_percentile": 33299.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 27749.78, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 27749.78, "10th_percentile": 27749.78, "90th_percentile": 27749.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 23764.91, "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": 23764.91, "10th_percentile": 23764.91, "90th_percentile": 23764.91, "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": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 17537.86, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 17537.86, "10th_percentile": 17537.86, "90th_percentile": 17537.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 19498.84, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19498.84, "10th_percentile": 19498.84, "90th_percentile": 19498.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 36999.7, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 36999.7, "10th_percentile": 36999.7, "90th_percentile": 36999.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $36,999.70 @ 12.5% = $4,624.96 due to $0.00 Claim Price", "median_amount": 4624.96, "10th_percentile": 4624.96, "90th_percentile": 4624.96, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $36,999.70 @ 12.5% = $4,624.96 due to $0.00 Claim Price" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $36,999.70 @ 6.8% = $2,515.98 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": 2515.98, "10th_percentile": 2515.98, "90th_percentile": 2515.98, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $36,999.70 @ 6.8% = $2,515.98 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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $36,999.70 @ 6.8% = $2,515.98 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": 2515.98, "10th_percentile": 2515.98, "90th_percentile": 2515.98, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $36,999.70 @ 6.8% = $2,515.98 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $36,999.70 @ 6.8% = $2,515.98 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": 2515.98, "10th_percentile": 2515.98, "90th_percentile": 2515.98, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $36,999.70 @ 6.8% = $2,515.98 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": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 36999.7, "10th_percentile": 36999.7, "90th_percentile": 36999.7, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 36999.7, "10th_percentile": 36999.7, "90th_percentile": 36999.7, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 36999.7, "10th_percentile": 36999.7, "90th_percentile": 36999.7, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 36999.7, "10th_percentile": 36999.7, "90th_percentile": 36999.7, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 36999.7, "10th_percentile": 36999.7, "90th_percentile": 36999.7, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 36999.7, "10th_percentile": 36999.7, "90th_percentile": 36999.7, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 36999.7, "10th_percentile": 36999.7, "90th_percentile": 36999.7, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "ADAPTER IV FOUR-SPIKE C7108 5", "code_information": [ { "code": "SUP-302424", "type": "CDM" }, { "code": "27000001", "type": "LOCAL" }, { "code": "0270", "type": "RC" } ], "standard_charges": [ { "minimum": 116.77, "maximum": 716.37, "setting": "outpatient", "gross_charge": 716.37, "discounted_cash": 501.46, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 258.18, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 258.18, "10th_percentile": 258.18, "90th_percentile": 258.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 202.59, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 202.59, "10th_percentile": 202.59, "90th_percentile": 202.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 400.45, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 400.45, "10th_percentile": 400.45, "90th_percentile": 400.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 499.45, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 499.45, "10th_percentile": 499.45, "90th_percentile": 499.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 200.58, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 200.58, "10th_percentile": 200.58, "90th_percentile": 200.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 206.6, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 206.6, "10th_percentile": 206.6, "90th_percentile": 206.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 444.15, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 444.15, "10th_percentile": 444.15, "90th_percentile": 444.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 444.15, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 444.15, "10th_percentile": 444.15, "90th_percentile": 444.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 644.73, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 644.73, "10th_percentile": 644.73, "90th_percentile": 644.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 644.73, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 644.73, "10th_percentile": 644.73, "90th_percentile": 644.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 608.91, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 608.91, "10th_percentile": 608.91, "90th_percentile": 608.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 465.64, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 465.64, "10th_percentile": 465.64, "90th_percentile": 465.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 358.19, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 358.19, "10th_percentile": 358.19, "90th_percentile": 358.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 537.28, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 537.28, "10th_percentile": 537.28, "90th_percentile": 537.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 156.17, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 156.17, "10th_percentile": 156.17, "90th_percentile": 156.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 573.1, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 573.1, "10th_percentile": 573.1, "90th_percentile": 573.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 351.02, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 351.02, "10th_percentile": 351.02, "90th_percentile": 351.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 573.1, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 573.1, "10th_percentile": 573.1, "90th_percentile": 573.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 494.3, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 494.3, "10th_percentile": 494.3, "90th_percentile": 494.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 339.56, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 339.56, "10th_percentile": 339.56, "90th_percentile": 339.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 716.37, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 716.37, "10th_percentile": 716.37, "90th_percentile": 716.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 377.53, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 377.53, "10th_percentile": 377.53, "90th_percentile": 377.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 451.31, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 451.31, "10th_percentile": 451.31, "90th_percentile": 451.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 486.42, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 486.42, "10th_percentile": 486.42, "90th_percentile": 486.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 116.77, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 116.77, "10th_percentile": 116.77, "90th_percentile": 116.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 499.45, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 499.45, "10th_percentile": 499.45, "90th_percentile": 499.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 358.19, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 358.19, "10th_percentile": 358.19, "90th_percentile": 358.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 258.18, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 258.18, "10th_percentile": 258.18, "90th_percentile": 258.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 716.37, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 716.37, "10th_percentile": 716.37, "90th_percentile": 716.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 537.28, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 537.28, "10th_percentile": 537.28, "90th_percentile": 537.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 460.12, "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": 460.12, "10th_percentile": 460.12, "90th_percentile": 460.12, "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": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 716.37, "10th_percentile": 716.37, "90th_percentile": 716.37, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 716.37, "10th_percentile": 716.37, "90th_percentile": 716.37, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 716.37, "10th_percentile": 716.37, "90th_percentile": 716.37, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 716.37, "10th_percentile": 716.37, "90th_percentile": 716.37, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 716.37, "10th_percentile": 716.37, "90th_percentile": 716.37, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 716.37, "10th_percentile": 716.37, "90th_percentile": 716.37, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 716.37, "10th_percentile": 716.37, "90th_percentile": 716.37, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 716.37, "10th_percentile": 716.37, "90th_percentile": 716.37, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 716.37, "10th_percentile": 716.37, "90th_percentile": 716.37, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 716.37, "10th_percentile": 716.37, "90th_percentile": 716.37, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 716.37, "10th_percentile": 716.37, "90th_percentile": 716.37, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "ADHESIVE SKIN AFFIX SURG TOPICAL .4 ML MSC091040Z - (DUP USE PS 381475)", "code_information": [ { "code": "SUP-347688", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 20.75, "maximum": 127.27, "setting": "outpatient", "gross_charge": 127.27, "discounted_cash": 89.09, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 67.07, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 67.07, "10th_percentile": 67.07, "90th_percentile": 67.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 127.27, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 127.27, "10th_percentile": 127.27, "90th_percentile": 127.27, "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": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 36.7, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 36.7, "10th_percentile": 36.7, "90th_percentile": 36.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 35.64, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 35.64, "10th_percentile": 35.64, "90th_percentile": 35.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 45.87, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 45.87, "10th_percentile": 45.87, "90th_percentile": 45.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 71.14, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 71.14, "10th_percentile": 71.14, "90th_percentile": 71.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 35.99, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 35.99, "10th_percentile": 35.99, "90th_percentile": 35.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 88.73, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 88.73, "10th_percentile": 88.73, "90th_percentile": 88.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 78.91, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 78.91, "10th_percentile": 78.91, "90th_percentile": 78.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 78.91, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 78.91, "10th_percentile": 78.91, "90th_percentile": 78.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 114.54, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 114.54, "10th_percentile": 114.54, "90th_percentile": 114.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 114.54, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 114.54, "10th_percentile": 114.54, "90th_percentile": 114.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 63.64, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 63.64, "10th_percentile": 63.64, "90th_percentile": 63.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 82.73, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 82.73, "10th_percentile": 82.73, "90th_percentile": 82.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 95.45, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 95.45, "10th_percentile": 95.45, "90th_percentile": 95.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 108.18, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 108.18, "10th_percentile": 108.18, "90th_percentile": 108.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 45.87, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 45.87, "10th_percentile": 45.87, "90th_percentile": 45.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 60.33, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 60.33, "10th_percentile": 60.33, "90th_percentile": 60.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 80.18, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 80.18, "10th_percentile": 80.18, "90th_percentile": 80.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 27.74, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 27.74, "10th_percentile": 27.74, "90th_percentile": 27.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 62.36, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 62.36, "10th_percentile": 62.36, "90th_percentile": 62.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 101.82, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 101.82, "10th_percentile": 101.82, "90th_percentile": 101.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 63.64, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 63.64, "10th_percentile": 63.64, "90th_percentile": 63.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 20.75, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% 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; 16.3% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 101.82, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 101.82, "10th_percentile": 101.82, "90th_percentile": 101.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 81.75, "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": 81.75, "10th_percentile": 81.75, "90th_percentile": 81.75, "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": "DCH PHCS", "standard_charge_dollar": 95.45, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 95.45, "10th_percentile": 95.45, "90th_percentile": 95.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 88.73, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 88.73, "10th_percentile": 88.73, "90th_percentile": 88.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 87.82, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 87.82, "10th_percentile": 87.82, "90th_percentile": 87.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 86.42, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 86.42, "10th_percentile": 86.42, "90th_percentile": 86.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 127.27, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 127.27, "10th_percentile": 127.27, "90th_percentile": 127.27, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 127.27, "10th_percentile": 127.27, "90th_percentile": 127.27, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 127.27, "10th_percentile": 127.27, "90th_percentile": 127.27, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 127.27, "10th_percentile": 127.27, "90th_percentile": 127.27, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 127.27, "10th_percentile": 127.27, "90th_percentile": 127.27, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 127.27, "10th_percentile": 127.27, "90th_percentile": 127.27, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 127.27, "10th_percentile": 127.27, "90th_percentile": 127.27, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 127.27, "10th_percentile": 127.27, "90th_percentile": 127.27, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 127.27, "10th_percentile": 127.27, "90th_percentile": 127.27, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 127.27, "10th_percentile": 127.27, "90th_percentile": 127.27, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 127.27, "10th_percentile": 127.27, "90th_percentile": 127.27, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 127.27, "10th_percentile": 127.27, "90th_percentile": 127.27, "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": 17552.52, "setting": "inpatient", "gross_charge": 46374.74, "discounted_cash": 32462.32, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.853907435; Using historical claim(s); Scope: All Financial Classes; Cases: 12; All IP Services; 100% Billed", "median_amount": 46374.75, "10th_percentile": 46374.75, "90th_percentile": 46374.75, "count": "12", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.853907435; Using historical claim(s); Scope: All Financial Classes; Cases: 12; All IP Services - OON; 100% Billed", "median_amount": 46374.75, "10th_percentile": 46374.75, "90th_percentile": 46374.75, "count": "12", "methodology": "percent of total billed charges" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.853907435; Using historical claim(s); Scope: All Financial Classes; Cases: 12; Inpatient (Non Covered - Verify Coverage); 100% Billed", "median_amount": 46374.75, "10th_percentile": 46374.75, "90th_percentile": 46374.75, "count": "12", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 34781.06, "10th_percentile": 34781.06, "90th_percentile": 34781.06, "count": "12", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH 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": 23187.38, "10th_percentile": 23187.38, "90th_percentile": 23187.38, "count": "12", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_percentage": 65.0, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 30143.59, "10th_percentile": 30143.59, "90th_percentile": 30143.59, "count": "12", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_percentage": 85.0, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 39418.54, "10th_percentile": 39418.54, "90th_percentile": 39418.54, "count": "12", "methodology": "percent of total billed charges" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_percentage": 90.0, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 41737.28, "10th_percentile": 41737.28, "90th_percentile": 41737.28, "count": "12", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_percentage": 90.0, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 41737.28, "10th_percentile": 41737.28, "90th_percentile": 41737.28, "count": "12", "methodology": "percent of total billed charges" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_percentage": 67.8, "standard_charge_algorithm": "Re-evaluated: HLB.853907435; Using historical claim(s); Scope: All Financial Classes; Cases: 12; All Inpatient Services; 67.8% Billed", "median_amount": 31442.08, "10th_percentile": 31442.08, "90th_percentile": 31442.08, "count": "12", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Re-evaluated: HLB.853907435; Using historical claim(s); Scope: All Financial Classes; Cases: 12; Inpatient Services; 63% Billed", "median_amount": 29216.09, "10th_percentile": 29216.09, "90th_percentile": 29216.09, "count": "12", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_percentage": 49.0, "standard_charge_algorithm": "Re-evaluated: HLB.853907435; Using historical claim(s); Scope: All Financial Classes; Cases: 12; IP Services. ADP RATE (for patient estimates only); 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 22723.63, "10th_percentile": 22723.63, "90th_percentile": 22723.63, "count": "12", "methodology": "percent of total billed charges" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH 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": 37099.8, "10th_percentile": 37099.8, "90th_percentile": 37099.8, "count": "12", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_percentage": 16.3, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 7559.11, "10th_percentile": 7559.11, "90th_percentile": 7559.11, "count": "12", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 17552.52, "standard_charge_algorithm": "Re-evaluated: HLB.853907435; Using historical claim(s); Scope: All Financial Classes; Cases: 12; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1261, Rate: 15,587.00, and; Pricing Extension - NM HB XR PRC - DCH 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": 17552.52, "10th_percentile": 17552.52, "90th_percentile": 17552.52, "count": "12", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 8469.4, "standard_charge_algorithm": "Re-evaluated: HLB.853907435; Using historical claim(s); Scope: All Financial Classes; Cases: 12; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1261, Rate: 7,521.00, and; Pricing Extension - NM HB XR PRC - DCH 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": 8469.4, "10th_percentile": 8469.4, "90th_percentile": 8469.4, "count": "12", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 17552.52, "standard_charge_algorithm": "Re-evaluated: HLB.853907435; Using historical claim(s); Scope: All Financial Classes; Cases: 12; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1261, Rate: 15,587.00, and; Pricing Extension - NM HB XR PRC - DCH 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": 17552.52, "10th_percentile": 17552.52, "90th_percentile": 17552.52, "count": "12", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 10113.5, "standard_charge_algorithm": "Re-evaluated: HLB.853907435; Using historical claim(s); Scope: All Financial Classes; Cases: 12; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1261, Rate: 8,981.00, and; Pricing Extension - NM HB XR PRC - DCH 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": 10113.5, "10th_percentile": 10113.5, "90th_percentile": 10113.5, "count": "12", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 8469.4, "standard_charge_algorithm": "Re-evaluated: HLB.853907435; Using historical claim(s); Scope: All Financial Classes; Cases: 12; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1261, Rate: 7,521.00, and; Pricing Extension - NM HB XR PRC - DCH 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": 8469.4, "10th_percentile": 8469.4, "90th_percentile": 8469.4, "count": "12", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 8357.91, "standard_charge_algorithm": "Re-evaluated: HLB.853907435; Using historical claim(s); Scope: All Financial Classes; Cases: 12; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1261, Rate: 7,422.00, and; Pricing Extension - NM HB XR PRC - DCH BCBS CHOICE SELECT CASE RATE W/OUTLIER S*", "median_amount": 8357.91, "10th_percentile": 8357.91, "90th_percentile": 8357.91, "count": "12", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 8525.7, "standard_charge_algorithm": "Re-evaluated: HLB.853907435; Using historical claim(s); Scope: All Financial Classes; Cases: 12; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1261, Rate: 7,571.00, and; Pricing Extension - NM HB XR PRC - DCH 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": 8525.7, "10th_percentile": 8525.7, "90th_percentile": 8525.7, "count": "12", "methodology": "case rate" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "DCH HUMANA MEDICARE ADVT", "standard_charge_dollar": 8013.14, "standard_charge_algorithm": "Re-evaluated: HLB.853907435; Using historical claim(s); Scope: All Financial Classes; Cases: 12; 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. Base payment: $8,650.13; Total: $8,650.13 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": 8650.13, "10th_percentile": 8650.13, "90th_percentile": 8650.13, "count": "12", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.853907435; Using historical claim(s); Scope: All Financial Classes; Cases: 12; 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. Base payment: $8,650.13; Total: $8,650.13 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." }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 8013.14, "standard_charge_algorithm": "Re-evaluated: HLB.853907435; Using historical claim(s); Scope: All Financial Classes; Cases: 12; 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. Base payment: $8,704.05; Total: $8,704.05 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8704.05, "10th_percentile": 8704.05, "90th_percentile": 8704.05, "count": "12", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.853907435; Using historical claim(s); Scope: All Financial Classes; Cases: 12; 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. Base payment: $8,704.05; Total: $8,704.05 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_dollar": 8013.14, "standard_charge_algorithm": "Re-evaluated: HLB.853907435; Using historical claim(s); Scope: All Financial Classes; Cases: 12; 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. Base payment: $8,704.05; Percentage applied: 97.00%; Total: $8,442.93 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": 8442.93, "10th_percentile": 8442.93, "90th_percentile": 8442.93, "count": "12", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.853907435; Using historical claim(s); Scope: All Financial Classes; Cases: 12; 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. Base payment: $8,704.05; Percentage applied: 97.00%; Total: $8,442.93 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." }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_dollar": 8013.14, "standard_charge_algorithm": "Re-evaluated: HLB.853907435; Using historical claim(s); Scope: All Financial Classes; Cases: 12; All DRGs (Plans excl O-IME); FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.13, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALCULATION EXCL O-IME; Note: Base payment: $8,704.05; Total: $8,704.05", "median_amount": 8704.05, "10th_percentile": 8704.05, "90th_percentile": 8704.05, "count": "12", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.853907435; Using historical claim(s); Scope: All Financial Classes; Cases: 12; All DRGs (Plans excl O-IME); FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.13, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALCULATION EXCL O-IME; Note: Base payment: $8,704.05; Total: $8,704.05" } ] } ] }, { "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": 123.26, "maximum": 827.25, "setting": "outpatient", "gross_charge": 827.25, "discounted_cash": 579.07, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 827.25, "10th_percentile": 827.25, "90th_percentile": 827.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 134.84, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 134.84, "10th_percentile": 134.84, "90th_percentile": 134.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 827.25, "10th_percentile": 827.25, "90th_percentile": 827.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 827.25, "10th_percentile": 827.25, "90th_percentile": 827.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 827.25, "10th_percentile": 827.25, "90th_percentile": 827.25, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 827.25, "10th_percentile": 827.25, "90th_percentile": 827.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 827.25, "10th_percentile": 827.25, "90th_percentile": 827.25, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 827.25, "10th_percentile": 827.25, "90th_percentile": 827.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $827.25 @ 12.5% = $103.41 due to $0.00 Claim Price", "median_amount": 103.41, "10th_percentile": 103.41, "90th_percentile": 103.41, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $827.25 @ 12.5% = $103.41 due to $0.00 Claim Price" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $827.25 @ 6.8% = $56.25 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": 56.25, "10th_percentile": 56.25, "90th_percentile": 56.25, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $827.25 @ 6.8% = $56.25 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $827.25 @ 6.8% = $56.25 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": 56.25, "10th_percentile": 56.25, "90th_percentile": 56.25, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $827.25 @ 6.8% = $56.25 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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $827.25 @ 6.8% = $56.25 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": 56.25, "10th_percentile": 56.25, "90th_percentile": 56.25, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $827.25 @ 6.8% = $56.25 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 BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 576.76, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 576.76, "10th_percentile": 576.76, "90th_percentile": 576.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 576.76, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 576.76, "10th_percentile": 576.76, "90th_percentile": 576.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 192.75, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 192.75, "10th_percentile": 192.75, "90th_percentile": 192.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 192.75, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 192.75, "10th_percentile": 192.75, "90th_percentile": 192.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 744.53, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 744.53, "10th_percentile": 744.53, "90th_percentile": 744.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 744.53, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 744.53, "10th_percentile": 744.53, "90th_percentile": 744.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 123.26, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 123.26, "10th_percentile": 123.26, "90th_percentile": 123.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 123.26, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 123.26, "10th_percentile": 123.26, "90th_percentile": 123.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH HFN PPO", "standard_charge_dollar": 703.16, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 703.16, "10th_percentile": 703.16, "90th_percentile": 703.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 413.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 413.63, "10th_percentile": 413.63, "90th_percentile": 413.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 620.44, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 620.44, "10th_percentile": 620.44, "90th_percentile": 620.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 537.71, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 537.71, "10th_percentile": 537.71, "90th_percentile": 537.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 413.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 413.63, "10th_percentile": 413.63, "90th_percentile": 413.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 462.43, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 462.43, "10th_percentile": 462.43, "90th_percentile": 462.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 521.17, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 521.17, "10th_percentile": 521.17, "90th_percentile": 521.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 620.44, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 620.44, "10th_percentile": 620.44, "90th_percentile": 620.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 661.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 661.8, "10th_percentile": 661.8, "90th_percentile": 661.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 570.8, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 570.8, "10th_percentile": 570.8, "90th_percentile": 570.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 827.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 827.25, "10th_percentile": 827.25, "90th_percentile": 827.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 661.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 661.8, "10th_percentile": 661.8, "90th_percentile": 661.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 827.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 827.25, "10th_percentile": 827.25, "90th_percentile": 827.25, "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": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 148.91, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 148.91, "10th_percentile": 148.91, "90th_percentile": 148.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "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": 113.24, "maximum": 760.0, "setting": "outpatient", "gross_charge": 760.0, "discounted_cash": 532.0, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 760.0, "10th_percentile": 760.0, "90th_percentile": 760.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 760.0, "10th_percentile": 760.0, "90th_percentile": 760.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 760.0, "10th_percentile": 760.0, "90th_percentile": 760.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 760.0, "10th_percentile": 760.0, "90th_percentile": 760.0, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 760.0, "10th_percentile": 760.0, "90th_percentile": 760.0, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 760.0, "10th_percentile": 760.0, "90th_percentile": 760.0, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 760.0, "10th_percentile": 760.0, "90th_percentile": 760.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $760.00 @ 6.8% = $51.68 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": 54.31, "10th_percentile": 54.31, "90th_percentile": 54.31, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $760.00 @ 6.8% = $51.68 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $760.00 @ 6.8% = $51.68 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": 54.31, "10th_percentile": 54.31, "90th_percentile": 54.31, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $760.00 @ 6.8% = $51.68 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": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $760.00 @ 6.8% = $51.68 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": 54.31, "10th_percentile": 54.31, "90th_percentile": 54.31, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $760.00 @ 6.8% = $51.68 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": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $760.00 @ 12.5% = $95.00 due to $0.00 Claim Price", "median_amount": 95.0, "10th_percentile": 95.0, "90th_percentile": 95.0, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $760.00 @ 12.5% = $95.00 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 177.08, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 177.08, "10th_percentile": 177.08, "90th_percentile": 177.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 177.08, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 177.08, "10th_percentile": 177.08, "90th_percentile": 177.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 113.24, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 113.24, "10th_percentile": 113.24, "90th_percentile": 113.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 113.24, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 113.24, "10th_percentile": 113.24, "90th_percentile": 113.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 529.87, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 529.87, "10th_percentile": 529.87, "90th_percentile": 529.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 529.87, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 529.87, "10th_percentile": 529.87, "90th_percentile": 529.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 684.0, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 684.0, "10th_percentile": 684.0, "90th_percentile": 684.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 684.0, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 684.0, "10th_percentile": 684.0, "90th_percentile": 684.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 380.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 380.0, "10th_percentile": 380.0, "90th_percentile": 380.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 646.0, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 646.0, "10th_percentile": 646.0, "90th_percentile": 646.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 494.0, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 494.0, "10th_percentile": 494.0, "90th_percentile": 494.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 570.0, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 570.0, "10th_percentile": 570.0, "90th_percentile": 570.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 478.8, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 478.8, "10th_percentile": 478.8, "90th_percentile": 478.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 760.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 760.0, "10th_percentile": 760.0, "90th_percentile": 760.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 570.0, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 570.0, "10th_percentile": 570.0, "90th_percentile": 570.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 380.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 380.0, "10th_percentile": 380.0, "90th_percentile": 380.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 608.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 608.0, "10th_percentile": 608.0, "90th_percentile": 608.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 524.4, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 524.4, "10th_percentile": 524.4, "90th_percentile": 524.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 760.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 760.0, "10th_percentile": 760.0, "90th_percentile": 760.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 608.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 608.0, "10th_percentile": 608.0, "90th_percentile": 608.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 424.84, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 424.84, "10th_percentile": 424.84, "90th_percentile": 424.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 123.88, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 31.92, "10th_percentile": 31.92, "90th_percentile": 31.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 136.8, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 136.8, "10th_percentile": 136.8, "90th_percentile": 136.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "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": "76125-0792-10", "type": "NDC" } ], "standard_charges": [ { "minimum": 103.26, "maximum": 693.0, "setting": "outpatient", "gross_charge": 693.0, "discounted_cash": 485.1, "payers_information": [ { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 693.0, "10th_percentile": 693.0, "90th_percentile": 693.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 693.0, "10th_percentile": 693.0, "90th_percentile": 693.0, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 693.0, "10th_percentile": 693.0, "90th_percentile": 693.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $693.00 @ 6.8% = $47.12 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": 47.12, "10th_percentile": 47.12, "90th_percentile": 47.12, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $693.00 @ 6.8% = $47.12 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": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 623.7, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 623.7, "10th_percentile": 623.7, "90th_percentile": 623.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 346.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 346.5, "10th_percentile": 346.5, "90th_percentile": 346.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 589.05, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 589.05, "10th_percentile": 589.05, "90th_percentile": 589.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 450.45, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 450.45, "10th_percentile": 450.45, "90th_percentile": 450.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 519.75, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 519.75, "10th_percentile": 519.75, "90th_percentile": 519.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 436.59, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 436.59, "10th_percentile": 436.59, "90th_percentile": 436.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 693.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 693.0, "10th_percentile": 693.0, "90th_percentile": 693.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 519.75, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 519.75, "10th_percentile": 519.75, "90th_percentile": 519.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 693.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 693.0, "10th_percentile": 693.0, "90th_percentile": 693.0, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 693.0, "10th_percentile": 693.0, "90th_percentile": 693.0, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 693.0, "10th_percentile": 693.0, "90th_percentile": 693.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 693.0, "10th_percentile": 693.0, "90th_percentile": 693.0, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 693.0, "10th_percentile": 693.0, "90th_percentile": 693.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $693.00 @ 12.5% = $86.63 due to $0.00 Claim Price", "median_amount": 86.63, "10th_percentile": 86.63, "90th_percentile": 86.63, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $693.00 @ 12.5% = $86.63 due to $0.00 Claim Price" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $693.00 @ 6.8% = $47.12 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": 47.12, "10th_percentile": 47.12, "90th_percentile": 47.12, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $693.00 @ 6.8% = $47.12 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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $693.00 @ 6.8% = $47.12 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": 47.12, "10th_percentile": 47.12, "90th_percentile": 47.12, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $693.00 @ 6.8% = $47.12 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 BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 483.16, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 483.16, "10th_percentile": 483.16, "90th_percentile": 483.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 483.16, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 483.16, "10th_percentile": 483.16, "90th_percentile": 483.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 161.47, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 161.47, "10th_percentile": 161.47, "90th_percentile": 161.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 161.47, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 161.47, "10th_percentile": 161.47, "90th_percentile": 161.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 623.7, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 623.7, "10th_percentile": 623.7, "90th_percentile": 623.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 103.26, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 103.26, "10th_percentile": 103.26, "90th_percentile": 103.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 103.26, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 103.26, "10th_percentile": 103.26, "90th_percentile": 103.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 346.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 346.5, "10th_percentile": 346.5, "90th_percentile": 346.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 387.39, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 387.39, "10th_percentile": 387.39, "90th_percentile": 387.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 554.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 554.4, "10th_percentile": 554.4, "90th_percentile": 554.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 478.17, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 478.17, "10th_percentile": 478.17, "90th_percentile": 478.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 554.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 554.4, "10th_percentile": 554.4, "90th_percentile": 554.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 124.74, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 124.74, "10th_percentile": 124.74, "90th_percentile": 124.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 112.96, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 112.96, "10th_percentile": 112.96, "90th_percentile": 112.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% 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": 129.7, "maximum": 870.5, "setting": "outpatient", "gross_charge": 870.5, "discounted_cash": 609.35, "payers_information": [ { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 870.5, "10th_percentile": 870.5, "90th_percentile": 870.5, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 870.5, "10th_percentile": 870.5, "90th_percentile": 870.5, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 870.5, "10th_percentile": 870.5, "90th_percentile": 870.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 870.5, "10th_percentile": 870.5, "90th_percentile": 870.5, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 870.5, "10th_percentile": 870.5, "90th_percentile": 870.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 870.5, "10th_percentile": 870.5, "90th_percentile": 870.5, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 870.5, "10th_percentile": 870.5, "90th_percentile": 870.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $870.50 @ 12.5% = $108.81 due to $0.00 Claim Price", "median_amount": 108.81, "10th_percentile": 108.81, "90th_percentile": 108.81, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $870.50 @ 12.5% = $108.81 due to $0.00 Claim Price" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $870.50 @ 6.8% = $59.19 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": 59.19, "10th_percentile": 59.19, "90th_percentile": 59.19, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $870.50 @ 6.8% = $59.19 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $870.50 @ 6.8% = $59.19 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": 59.19, "10th_percentile": 59.19, "90th_percentile": 59.19, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $870.50 @ 6.8% = $59.19 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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $870.50 @ 6.8% = $59.19 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": 59.19, "10th_percentile": 59.19, "90th_percentile": 59.19, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $870.50 @ 6.8% = $59.19 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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 202.83, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 202.83, "10th_percentile": 202.83, "90th_percentile": 202.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 156.69, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 156.69, "10th_percentile": 156.69, "90th_percentile": 156.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 486.61, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 486.61, "10th_percentile": 486.61, "90th_percentile": 486.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 606.91, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 606.91, "10th_percentile": 606.91, "90th_percentile": 606.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 129.7, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 129.7, "10th_percentile": 129.7, "90th_percentile": 129.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 129.7, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 129.7, "10th_percentile": 129.7, "90th_percentile": 129.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 783.45, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 783.45, "10th_percentile": 783.45, "90th_percentile": 783.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 783.45, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 783.45, "10th_percentile": 783.45, "90th_percentile": 783.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 565.83, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 565.83, "10th_percentile": 565.83, "90th_percentile": 565.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 652.88, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 652.88, "10th_percentile": 652.88, "90th_percentile": 652.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 435.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 435.25, "10th_percentile": 435.25, "90th_percentile": 435.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 739.93, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 739.93, "10th_percentile": 739.93, "90th_percentile": 739.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 606.91, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 606.91, "10th_percentile": 606.91, "90th_percentile": 606.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 600.65, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 600.65, "10th_percentile": 600.65, "90th_percentile": 600.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 696.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 696.4, "10th_percentile": 696.4, "90th_percentile": 696.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 435.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 435.25, "10th_percentile": 435.25, "90th_percentile": 435.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 652.88, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 652.88, "10th_percentile": 652.88, "90th_percentile": 652.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 548.42, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 548.42, "10th_percentile": 548.42, "90th_percentile": 548.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 696.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 696.4, "10th_percentile": 696.4, "90th_percentile": 696.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 141.89, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 141.89, "10th_percentile": 141.89, "90th_percentile": 141.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 870.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 870.5, "10th_percentile": 870.5, "90th_percentile": 870.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 202.83, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 202.83, "10th_percentile": 202.83, "90th_percentile": 202.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 870.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 870.5, "10th_percentile": 870.5, "90th_percentile": 870.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "ALBUTEROL SULFATE 2.5 MG /3 ML (0.083 %) INH NEBU", "drug_information": { "unit": 3.0, "type": "ML" }, "code_information": [ { "code": "RX-250", "type": "CDM" }, { "code": "J3490", "type": "HCPCS" }, { "code": "0250", "type": "RC" }, { "code": "00487-9501-25", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.82, "maximum": 5.5, "setting": "outpatient", "gross_charge": 5.5, "discounted_cash": 3.85, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5.5, "10th_percentile": 5.5, "90th_percentile": 5.5, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5.5, "10th_percentile": 5.5, "90th_percentile": 5.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5.5, "10th_percentile": 5.5, "90th_percentile": 5.5, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5.5, "10th_percentile": 5.5, "90th_percentile": 5.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5.5, "10th_percentile": 5.5, "90th_percentile": 5.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5.5, "10th_percentile": 5.5, "90th_percentile": 5.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $5.50 @ 12.5% = $0.69 due to $0.00 Claim Price", "median_amount": 0.69, "10th_percentile": 0.69, "90th_percentile": 0.69, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $5.50 @ 12.5% = $0.69 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $5.50 @ 6.8% = $0.37 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": 0.37, "10th_percentile": 0.37, "90th_percentile": 0.37, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $5.50 @ 6.8% = $0.37 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": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $5.50 @ 6.8% = $0.37 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": 0.37, "10th_percentile": 0.37, "90th_percentile": 0.37, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $5.50 @ 6.8% = $0.37 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $5.50 @ 6.8% = $0.37 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": 0.37, "10th_percentile": 0.37, "90th_percentile": 0.37, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $5.50 @ 6.8% = $0.37 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": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 5.5, "10th_percentile": 5.5, "90th_percentile": 5.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 3.41, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "Drugs/Agents Default; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.41, "10th_percentile": 3.41, "90th_percentile": 3.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 3.73, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "Drugs/Agents Default; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.73, "10th_percentile": 3.73, "90th_percentile": 3.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.9, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 0.9, "10th_percentile": 0.9, "90th_percentile": 0.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 3.83, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.83, "10th_percentile": 3.83, "90th_percentile": 3.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 1.28, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 1.28, "10th_percentile": 1.28, "90th_percentile": 1.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 4.95, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 4.95, "10th_percentile": 4.95, "90th_percentile": 4.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.82, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.82, "10th_percentile": 0.82, "90th_percentile": 0.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.99, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.99, "10th_percentile": 0.99, "90th_percentile": 0.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.82, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.82, "10th_percentile": 0.82, "90th_percentile": 0.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 3.83, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.83, "10th_percentile": 3.83, "90th_percentile": 3.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 3.07, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.07, "10th_percentile": 3.07, "90th_percentile": 3.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 1.28, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 1.28, "10th_percentile": 1.28, "90th_percentile": 1.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 2.75, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 4.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 4.4, "10th_percentile": 4.4, "90th_percentile": 4.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 4.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 4.4, "10th_percentile": 4.4, "90th_percentile": 4.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 3.41, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "Drugs/Agents Default; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.41, "10th_percentile": 3.41, "90th_percentile": 3.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 3.8, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 3.8, "10th_percentile": 3.8, "90th_percentile": 3.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 4.13, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 4.13, "10th_percentile": 4.13, "90th_percentile": 4.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 2.75, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% 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 OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 3.58, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 3.58, "10th_percentile": 3.58, "90th_percentile": 3.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 4.68, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 4.68, "10th_percentile": 4.68, "90th_percentile": 4.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 3.47, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 3.47, "10th_percentile": 3.47, "90th_percentile": 3.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 4.95, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 4.95, "10th_percentile": 4.95, "90th_percentile": 4.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5.5, "10th_percentile": 5.5, "90th_percentile": 5.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 4.13, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 4.13, "10th_percentile": 4.13, "90th_percentile": 4.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 3.53, "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": 3.53, "10th_percentile": 3.53, "90th_percentile": 3.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 2.61, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.61, "10th_percentile": 2.61, "90th_percentile": 2.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 2.9, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.9, "10th_percentile": 2.9, "90th_percentile": 2.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 5.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 5.5, "10th_percentile": 5.5, "90th_percentile": 5.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" } ] } ] }, { "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": 1.87, "maximum": 11.5, "setting": "outpatient", "gross_charge": 11.5, "discounted_cash": 8.05, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11.5, "10th_percentile": 11.5, "90th_percentile": 11.5, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11.5, "10th_percentile": 11.5, "90th_percentile": 11.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11.5, "10th_percentile": 11.5, "90th_percentile": 11.5, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11.5, "10th_percentile": 11.5, "90th_percentile": 11.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11.5, "10th_percentile": 11.5, "90th_percentile": 11.5, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11.5, "10th_percentile": 11.5, "90th_percentile": 11.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11.5, "10th_percentile": 11.5, "90th_percentile": 11.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11.5, "10th_percentile": 11.5, "90th_percentile": 11.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11.5, "10th_percentile": 11.5, "90th_percentile": 11.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11.5, "10th_percentile": 11.5, "90th_percentile": 11.5, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 11.5, "10th_percentile": 11.5, "90th_percentile": 11.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 7.13, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 7.81, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.81, "10th_percentile": 7.81, "90th_percentile": 7.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 1.87, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 1.87, "10th_percentile": 1.87, "90th_percentile": 1.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 8.02, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.02, "10th_percentile": 8.02, "90th_percentile": 8.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 4.14, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.14, "10th_percentile": 4.14, "90th_percentile": 4.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 10.35, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 10.35, "10th_percentile": 10.35, "90th_percentile": 10.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 3.32, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.32, "10th_percentile": 3.32, "90th_percentile": 3.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 3.25, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.25, "10th_percentile": 3.25, "90th_percentile": 3.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 3.22, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.22, "10th_percentile": 3.22, "90th_percentile": 3.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 8.02, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.02, "10th_percentile": 8.02, "90th_percentile": 8.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 6.43, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.43, "10th_percentile": 6.43, "90th_percentile": 6.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 4.14, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.14, "10th_percentile": 4.14, "90th_percentile": 4.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 5.75, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.75, "10th_percentile": 5.75, "90th_percentile": 5.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 2.51, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.51, "10th_percentile": 2.51, "90th_percentile": 2.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 9.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 9.2, "10th_percentile": 9.2, "90th_percentile": 9.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 5.64, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.64, "10th_percentile": 5.64, "90th_percentile": 5.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 9.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 9.2, "10th_percentile": 9.2, "90th_percentile": 9.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 7.13, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 7.94, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 7.94, "10th_percentile": 7.94, "90th_percentile": 7.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 8.63, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 8.63, "10th_percentile": 8.63, "90th_percentile": 8.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 5.75, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% 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 OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 7.48, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 7.48, "10th_percentile": 7.48, "90th_percentile": 7.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 9.78, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 9.78, "10th_percentile": 9.78, "90th_percentile": 9.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 7.25, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 7.25, "10th_percentile": 7.25, "90th_percentile": 7.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 10.35, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 10.35, "10th_percentile": 10.35, "90th_percentile": 10.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 11.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 11.5, "10th_percentile": 11.5, "90th_percentile": 11.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 8.63, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 8.63, "10th_percentile": 8.63, "90th_percentile": 8.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 7.39, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 7.39, "10th_percentile": 7.39, "90th_percentile": 7.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 5.45, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.45, "10th_percentile": 5.45, "90th_percentile": 5.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 6.06, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.06, "10th_percentile": 6.06, "90th_percentile": 6.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 11.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 11.5, "10th_percentile": 11.5, "90th_percentile": 11.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" } ] } ] }, { "description": "ALLOPURINOL 100 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-310", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "00591-5543-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.14, "maximum": 7.0, "setting": "outpatient", "gross_charge": 7.0, "discounted_cash": 4.9, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1.96, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.96, "10th_percentile": 1.96, "90th_percentile": 1.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 3.91, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.91, "10th_percentile": 3.91, "90th_percentile": 3.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 2.52, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.52, "10th_percentile": 2.52, "90th_percentile": 2.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1.98, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.98, "10th_percentile": 1.98, "90th_percentile": 1.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 2.02, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 4.88, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.88, "10th_percentile": 4.88, "90th_percentile": 4.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 4.34, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.34, "10th_percentile": 4.34, "90th_percentile": 4.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 6.3, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 6.3, "10th_percentile": 6.3, "90th_percentile": 6.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 1.14, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 4.75, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 4.88, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.88, "10th_percentile": 4.88, "90th_percentile": 4.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 2.52, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.52, "10th_percentile": 2.52, "90th_percentile": 2.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 3.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.5, "10th_percentile": 3.5, "90th_percentile": 3.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 1.53, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.53, "10th_percentile": 1.53, "90th_percentile": 1.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual 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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 7.0, "10th_percentile": 7.0, "90th_percentile": 7.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 7.0, "10th_percentile": 7.0, "90th_percentile": 7.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 7.0, "10th_percentile": 7.0, "90th_percentile": 7.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 7.0, "10th_percentile": 7.0, "90th_percentile": 7.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 7.0, "10th_percentile": 7.0, "90th_percentile": 7.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 7.0, "10th_percentile": 7.0, "90th_percentile": 7.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 7.0, "10th_percentile": 7.0, "90th_percentile": 7.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 7.0, "10th_percentile": 7.0, "90th_percentile": 7.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 7.0, "10th_percentile": 7.0, "90th_percentile": 7.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 7.0, "10th_percentile": 7.0, "90th_percentile": 7.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 7.0, "10th_percentile": 7.0, "90th_percentile": 7.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 4.34, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.34, "10th_percentile": 4.34, "90th_percentile": 4.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 6.3, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 6.3, "10th_percentile": 6.3, "90th_percentile": 6.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 5.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 5.25, "10th_percentile": 5.25, "90th_percentile": 5.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 4.55, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 4.55, "10th_percentile": 4.55, "90th_percentile": 4.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 3.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 3.5, "10th_percentile": 3.5, "90th_percentile": 3.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 5.95, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 5.95, "10th_percentile": 5.95, "90th_percentile": 5.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 3.32, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.32, "10th_percentile": 3.32, "90th_percentile": 3.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 3.69, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.69, "10th_percentile": 3.69, "90th_percentile": 3.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 7.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 7.0, "10th_percentile": 7.0, "90th_percentile": 7.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7.0, "10th_percentile": 7.0, "90th_percentile": 7.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 3.43, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.43, "10th_percentile": 3.43, "90th_percentile": 3.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 5.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 5.6, "10th_percentile": 5.6, "90th_percentile": 5.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 4.5, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 4.5, "10th_percentile": 4.5, "90th_percentile": 4.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 4.41, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 4.41, "10th_percentile": 4.41, "90th_percentile": 4.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 5.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 5.6, "10th_percentile": 5.6, "90th_percentile": 5.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 4.83, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 4.83, "10th_percentile": 4.83, "90th_percentile": 4.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 5.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 5.25, "10th_percentile": 5.25, "90th_percentile": 5.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" } ] } ] }, { "description": "ALPRAZOLAM 0.25 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-324", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "60687-0377-11", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.82, "maximum": 5.0, "setting": "outpatient", "gross_charge": 5.0, "discounted_cash": 3.5, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1.4, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.4, "10th_percentile": 1.4, "90th_percentile": 1.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2.8, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.8, "10th_percentile": 2.8, "90th_percentile": 2.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 1.8, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.8, "10th_percentile": 1.8, "90th_percentile": 1.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1.41, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1.44, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.44, "10th_percentile": 1.44, "90th_percentile": 1.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 3.49, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.49, "10th_percentile": 3.49, "90th_percentile": 3.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 3.1, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.1, "10th_percentile": 3.1, "90th_percentile": 3.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 3.1, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.1, "10th_percentile": 3.1, "90th_percentile": 3.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 4.5, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% 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 SERVICES; 90% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.82, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% 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; 16.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 3.4, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.4, "10th_percentile": 3.4, "90th_percentile": 3.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 3.49, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.49, "10th_percentile": 3.49, "90th_percentile": 3.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 1.8, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.8, "10th_percentile": 1.8, "90th_percentile": 1.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 2.45, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.45, "10th_percentile": 2.45, "90th_percentile": 2.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 2.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.5, "10th_percentile": 2.5, "90th_percentile": 2.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 4.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 4.0, "10th_percentile": 4.0, "90th_percentile": 4.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 3.45, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% 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 Outpatient Services; 69% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 1.09, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.09, "10th_percentile": 1.09, "90th_percentile": 1.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 4.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 4.0, "10th_percentile": 4.0, "90th_percentile": 4.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5.0, "10th_percentile": 5.0, "90th_percentile": 5.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5.0, "10th_percentile": 5.0, "90th_percentile": 5.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5.0, "10th_percentile": 5.0, "90th_percentile": 5.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5.0, "10th_percentile": 5.0, "90th_percentile": 5.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5.0, "10th_percentile": 5.0, "90th_percentile": 5.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5.0, "10th_percentile": 5.0, "90th_percentile": 5.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5.0, "10th_percentile": 5.0, "90th_percentile": 5.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5.0, "10th_percentile": 5.0, "90th_percentile": 5.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5.0, "10th_percentile": 5.0, "90th_percentile": 5.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5.0, "10th_percentile": 5.0, "90th_percentile": 5.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 5.0, "10th_percentile": 5.0, "90th_percentile": 5.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 4.5, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% 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 SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 3.75, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 3.75, "10th_percentile": 3.75, "90th_percentile": 3.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 3.25, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 3.25, "10th_percentile": 3.25, "90th_percentile": 3.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 2.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 2.5, "10th_percentile": 2.5, "90th_percentile": 2.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 4.25, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 4.25, "10th_percentile": 4.25, "90th_percentile": 4.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 2.37, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.37, "10th_percentile": 2.37, "90th_percentile": 2.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 2.64, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.64, "10th_percentile": 2.64, "90th_percentile": 2.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 5.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 5.0, "10th_percentile": 5.0, "90th_percentile": 5.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5.0, "10th_percentile": 5.0, "90th_percentile": 5.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 3.21, "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": 3.21, "10th_percentile": 3.21, "90th_percentile": 3.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 3.15, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 3.15, "10th_percentile": 3.15, "90th_percentile": 3.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 3.75, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 3.75, "10th_percentile": 3.75, "90th_percentile": 3.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" } ] } ] }, { "description": "ALPRAZOLAM 0.5 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-325", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "65862-0677-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.73, "maximum": 4.5, "setting": "outpatient", "gross_charge": 4.5, "discounted_cash": 3.15, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "DCH 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": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS 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": "DCH 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": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH 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": "GLOBAL EXCEL [1712]", "plan_name": "DCH 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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "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": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "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": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "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": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "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": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 4.05, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% 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 SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 4.05, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% 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 SERVICES; 90% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 2.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 2.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 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 SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 3.38, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 3.38, "10th_percentile": 3.38, "90th_percentile": 3.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 3.38, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 3.38, "10th_percentile": 3.38, "90th_percentile": 3.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 2.79, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.79, "10th_percentile": 2.79, "90th_percentile": 2.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 2.79, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.79, "10th_percentile": 2.79, "90th_percentile": 2.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH 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": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 3.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 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 DEF; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 3.14, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.14, "10th_percentile": 3.14, "90th_percentile": 3.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 3.14, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.14, "10th_percentile": 3.14, "90th_percentile": 3.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH 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": "MULTIPLAN/PHCS [142]", "plan_name": "DCH 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": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 1.62, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.62, "10th_percentile": 1.62, "90th_percentile": 1.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 1.62, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.62, "10th_percentile": 1.62, "90th_percentile": 1.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 0.98, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.98, "10th_percentile": 0.98, "90th_percentile": 0.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH HFN PLAT", "standard_charge_dollar": 2.93, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% 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 procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1.26, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.26, "10th_percentile": 1.26, "90th_percentile": 1.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1.27, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.27, "10th_percentile": 1.27, "90th_percentile": 1.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2.52, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.52, "10th_percentile": 2.52, "90th_percentile": 2.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1.3, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH 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": "DCH 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": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 3.11, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 3.11, "10th_percentile": 3.11, "90th_percentile": 3.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 2.21, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.21, "10th_percentile": 2.21, "90th_percentile": 2.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 3.83, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 3.83, "10th_percentile": 3.83, "90th_percentile": 3.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 2.13, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.13, "10th_percentile": 2.13, "90th_percentile": 2.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 2.37, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.37, "10th_percentile": 2.37, "90th_percentile": 2.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.73, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 0.73, "10th_percentile": 0.73, "90th_percentile": 0.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 3.06, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.06, "10th_percentile": 3.06, "90th_percentile": 3.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "AMANTADINE HCL 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": 81.54, "maximum": 500.25, "setting": "outpatient", "gross_charge": 500.25, "discounted_cash": 350.17, "payers_information": [ { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 321.31, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 321.31, "10th_percentile": 321.31, "90th_percentile": 321.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - 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": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 500.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 500.25, "10th_percentile": 500.25, "90th_percentile": 500.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 315.16, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 315.16, "10th_percentile": 315.16, "90th_percentile": 315.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 400.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 400.2, "10th_percentile": 400.2, "90th_percentile": 400.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 237.12, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 237.12, "10th_percentile": 237.12, "90th_percentile": 237.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 263.63, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 263.63, "10th_percentile": 263.63, "90th_percentile": 263.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 500.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 500.25, "10th_percentile": 500.25, "90th_percentile": 500.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 345.17, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 345.17, "10th_percentile": 345.17, "90th_percentile": 345.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 250.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 250.13, "10th_percentile": 250.13, "90th_percentile": 250.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 375.19, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 375.19, "10th_percentile": 375.19, "90th_percentile": 375.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 400.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 400.2, "10th_percentile": 400.2, "90th_percentile": 400.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 109.05, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 109.05, "10th_percentile": 109.05, "90th_percentile": 109.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 245.12, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 245.12, "10th_percentile": 245.12, "90th_percentile": 245.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 339.67, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 339.67, "10th_percentile": 339.67, "90th_percentile": 339.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 81.54, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 81.54, "10th_percentile": 81.54, "90th_percentile": 81.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 348.77, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 348.77, "10th_percentile": 348.77, "90th_percentile": 348.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 180.29, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 180.29, "10th_percentile": 180.29, "90th_percentile": 180.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH HFN PLAT", "standard_charge_dollar": 325.16, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 325.16, "10th_percentile": 325.16, "90th_percentile": 325.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 425.21, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 425.21, "10th_percentile": 425.21, "90th_percentile": 425.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 250.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 250.13, "10th_percentile": 250.13, "90th_percentile": 250.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 375.19, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 375.19, "10th_percentile": 375.19, "90th_percentile": 375.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 279.64, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 279.64, "10th_percentile": 279.64, "90th_percentile": 279.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 348.77, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 348.77, "10th_percentile": 348.77, "90th_percentile": 348.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 140.07, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 140.07, "10th_percentile": 140.07, "90th_percentile": 140.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 141.47, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 141.47, "10th_percentile": 141.47, "90th_percentile": 141.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 180.29, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 180.29, "10th_percentile": 180.29, "90th_percentile": 180.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 144.27, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 144.27, "10th_percentile": 144.27, "90th_percentile": 144.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 310.16, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 310.16, "10th_percentile": 310.16, "90th_percentile": 310.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 310.16, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 310.16, "10th_percentile": 310.16, "90th_percentile": 310.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 450.23, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 450.23, "10th_percentile": 450.23, "90th_percentile": 450.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 450.23, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 450.23, "10th_percentile": 450.23, "90th_percentile": 450.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 500.25, "10th_percentile": 500.25, "90th_percentile": 500.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 500.25, "10th_percentile": 500.25, "90th_percentile": 500.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 500.25, "10th_percentile": 500.25, "90th_percentile": 500.25, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 500.25, "10th_percentile": 500.25, "90th_percentile": 500.25, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 500.25, "10th_percentile": 500.25, "90th_percentile": 500.25, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 500.25, "10th_percentile": 500.25, "90th_percentile": 500.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 500.25, "10th_percentile": 500.25, "90th_percentile": 500.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 500.25, "10th_percentile": 500.25, "90th_percentile": 500.25, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 500.25, "10th_percentile": 500.25, "90th_percentile": 500.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 500.25, "10th_percentile": 500.25, "90th_percentile": 500.25, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 500.25, "10th_percentile": 500.25, "90th_percentile": 500.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "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": 18.51, "maximum": 124.25, "setting": "outpatient", "gross_charge": 124.25, "discounted_cash": 86.97, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 124.25, "10th_percentile": 124.25, "90th_percentile": 124.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 124.25, "10th_percentile": 124.25, "90th_percentile": 124.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 124.25, "10th_percentile": 124.25, "90th_percentile": 124.25, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 124.25, "10th_percentile": 124.25, "90th_percentile": 124.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 124.25, "10th_percentile": 124.25, "90th_percentile": 124.25, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 124.25, "10th_percentile": 124.25, "90th_percentile": 124.25, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 124.25, "10th_percentile": 124.25, "90th_percentile": 124.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $124.25 @ 12.5% = $15.53 due to $0.00 Claim Price", "median_amount": 15.53, "10th_percentile": 15.53, "90th_percentile": 15.53, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $124.25 @ 12.5% = $15.53 due to $0.00 Claim Price" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $124.25 @ 6.8% = $8.45 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": 8.45, "10th_percentile": 8.45, "90th_percentile": 8.45, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $124.25 @ 6.8% = $8.45 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $124.25 @ 6.8% = $8.45 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": 8.45, "10th_percentile": 8.45, "90th_percentile": 8.45, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $124.25 @ 6.8% = $8.45 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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $124.25 @ 6.8% = $8.45 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": 8.45, "10th_percentile": 8.45, "90th_percentile": 8.45, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $124.25 @ 6.8% = $8.45 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 BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 86.63, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 86.63, "10th_percentile": 86.63, "90th_percentile": 86.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 86.63, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 86.63, "10th_percentile": 86.63, "90th_percentile": 86.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 28.95, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 28.95, "10th_percentile": 28.95, "90th_percentile": 28.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 28.95, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 28.95, "10th_percentile": 28.95, "90th_percentile": 28.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 111.83, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 111.83, "10th_percentile": 111.83, "90th_percentile": 111.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 111.83, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 111.83, "10th_percentile": 111.83, "90th_percentile": 111.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 18.51, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 18.51, "10th_percentile": 18.51, "90th_percentile": 18.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 18.51, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 18.51, "10th_percentile": 18.51, "90th_percentile": 18.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH HFN PPO", "standard_charge_dollar": 105.61, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 105.61, "10th_percentile": 105.61, "90th_percentile": 105.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 62.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 62.13, "10th_percentile": 62.13, "90th_percentile": 62.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 93.19, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 93.19, "10th_percentile": 93.19, "90th_percentile": 93.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 80.76, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 80.76, "10th_percentile": 80.76, "90th_percentile": 80.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 62.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 62.13, "10th_percentile": 62.13, "90th_percentile": 62.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 69.46, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 69.46, "10th_percentile": 69.46, "90th_percentile": 69.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 78.28, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 78.28, "10th_percentile": 78.28, "90th_percentile": 78.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 93.19, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 93.19, "10th_percentile": 93.19, "90th_percentile": 93.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 99.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 99.4, "10th_percentile": 99.4, "90th_percentile": 99.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 85.73, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 85.73, "10th_percentile": 85.73, "90th_percentile": 85.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 124.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 124.25, "10th_percentile": 124.25, "90th_percentile": 124.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 99.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 99.4, "10th_percentile": 99.4, "90th_percentile": 99.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 124.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 124.25, "10th_percentile": 124.25, "90th_percentile": 124.25, "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": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 22.37, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 22.37, "10th_percentile": 22.37, "90th_percentile": 22.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 20.25, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 20.25, "10th_percentile": 20.25, "90th_percentile": 20.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% 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": 5.48, "maximum": 36.75, "setting": "outpatient", "gross_charge": 36.75, "discounted_cash": 25.72, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 36.75, "10th_percentile": 36.75, "90th_percentile": 36.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 36.75, "10th_percentile": 36.75, "90th_percentile": 36.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 36.75, "10th_percentile": 36.75, "90th_percentile": 36.75, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 36.75, "10th_percentile": 36.75, "90th_percentile": 36.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 36.75, "10th_percentile": 36.75, "90th_percentile": 36.75, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 36.75, "10th_percentile": 36.75, "90th_percentile": 36.75, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 36.75, "10th_percentile": 36.75, "90th_percentile": 36.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $36.75 @ 12.5% = $4.59 due to $0.00 Claim Price", "median_amount": 4.59, "10th_percentile": 4.59, "90th_percentile": 4.59, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $36.75 @ 12.5% = $4.59 due to $0.00 Claim Price" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $36.75 @ 6.8% = $2.50 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": 2.5, "10th_percentile": 2.5, "90th_percentile": 2.5, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $36.75 @ 6.8% = $2.50 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $36.75 @ 6.8% = $2.50 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": 2.5, "10th_percentile": 2.5, "90th_percentile": 2.5, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $36.75 @ 6.8% = $2.50 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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $36.75 @ 6.8% = $2.50 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": 2.5, "10th_percentile": 2.5, "90th_percentile": 2.5, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $36.75 @ 6.8% = $2.50 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 BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 25.62, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 25.62, "10th_percentile": 25.62, "90th_percentile": 25.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 25.62, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 25.62, "10th_percentile": 25.62, "90th_percentile": 25.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 8.56, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 8.56, "10th_percentile": 8.56, "90th_percentile": 8.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 8.56, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 8.56, "10th_percentile": 8.56, "90th_percentile": 8.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 33.08, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 33.08, "10th_percentile": 33.08, "90th_percentile": 33.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 33.08, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 33.08, "10th_percentile": 33.08, "90th_percentile": 33.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 5.48, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.48, "10th_percentile": 5.48, "90th_percentile": 5.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 5.48, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.48, "10th_percentile": 5.48, "90th_percentile": 5.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH HFN PPO", "standard_charge_dollar": 31.24, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 31.24, "10th_percentile": 31.24, "90th_percentile": 31.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 18.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 18.38, "10th_percentile": 18.38, "90th_percentile": 18.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 27.56, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 27.56, "10th_percentile": 27.56, "90th_percentile": 27.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 23.89, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% 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 procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 18.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 18.38, "10th_percentile": 18.38, "90th_percentile": 18.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 20.54, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.54, "10th_percentile": 20.54, "90th_percentile": 20.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 23.15, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 23.15, "10th_percentile": 23.15, "90th_percentile": 23.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 27.56, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 27.56, "10th_percentile": 27.56, "90th_percentile": 27.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 29.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 29.4, "10th_percentile": 29.4, "90th_percentile": 29.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 25.36, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 25.36, "10th_percentile": 25.36, "90th_percentile": 25.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 36.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% 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 OP Services - OON; 100% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 29.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 29.4, "10th_percentile": 29.4, "90th_percentile": 29.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 36.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% 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 OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 6.62, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.62, "10th_percentile": 6.62, "90th_percentile": 6.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 5.99, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 5.99, "10th_percentile": 5.99, "90th_percentile": 5.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% 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": 38.85, "maximum": 260.75, "setting": "outpatient", "gross_charge": 260.75, "discounted_cash": 182.52, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 260.75, "10th_percentile": 260.75, "90th_percentile": 260.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 42.5, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 42.5, "10th_percentile": 42.5, "90th_percentile": 42.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 260.75, "10th_percentile": 260.75, "90th_percentile": 260.75, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 260.75, "10th_percentile": 260.75, "90th_percentile": 260.75, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 260.75, "10th_percentile": 260.75, "90th_percentile": 260.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 260.75, "10th_percentile": 260.75, "90th_percentile": 260.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 260.75, "10th_percentile": 260.75, "90th_percentile": 260.75, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 260.75, "10th_percentile": 260.75, "90th_percentile": 260.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $260.75 @ 12.5% = $32.59 due to $0.00 Claim Price", "median_amount": 32.59, "10th_percentile": 32.59, "90th_percentile": 32.59, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $260.75 @ 12.5% = $32.59 due to $0.00 Claim Price" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $260.75 @ 6.8% = $17.73 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": 17.73, "10th_percentile": 17.73, "90th_percentile": 17.73, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $260.75 @ 6.8% = $17.73 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $260.75 @ 6.8% = $17.73 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": 17.73, "10th_percentile": 17.73, "90th_percentile": 17.73, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $260.75 @ 6.8% = $17.73 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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $260.75 @ 6.8% = $17.73 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": 17.73, "10th_percentile": 17.73, "90th_percentile": 17.73, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $260.75 @ 6.8% = $17.73 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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 60.75, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 60.75, "10th_percentile": 60.75, "90th_percentile": 60.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 46.94, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 46.94, "10th_percentile": 46.94, "90th_percentile": 46.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 145.76, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 145.76, "10th_percentile": 145.76, "90th_percentile": 145.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 181.79, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 181.79, "10th_percentile": 181.79, "90th_percentile": 181.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 38.85, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 38.85, "10th_percentile": 38.85, "90th_percentile": 38.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 38.85, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 38.85, "10th_percentile": 38.85, "90th_percentile": 38.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 234.68, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 234.68, "10th_percentile": 234.68, "90th_percentile": 234.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 234.68, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 234.68, "10th_percentile": 234.68, "90th_percentile": 234.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 169.49, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 169.49, "10th_percentile": 169.49, "90th_percentile": 169.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 195.56, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 195.56, "10th_percentile": 195.56, "90th_percentile": 195.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 130.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 130.38, "10th_percentile": 130.38, "90th_percentile": 130.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 221.64, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 221.64, "10th_percentile": 221.64, "90th_percentile": 221.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 181.79, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 181.79, "10th_percentile": 181.79, "90th_percentile": 181.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 179.92, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 179.92, "10th_percentile": 179.92, "90th_percentile": 179.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 208.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 208.6, "10th_percentile": 208.6, "90th_percentile": 208.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 130.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 130.38, "10th_percentile": 130.38, "90th_percentile": 130.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 195.56, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 195.56, "10th_percentile": 195.56, "90th_percentile": 195.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 164.27, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 164.27, "10th_percentile": 164.27, "90th_percentile": 164.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 208.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 208.6, "10th_percentile": 208.6, "90th_percentile": 208.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 260.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 260.75, "10th_percentile": 260.75, "90th_percentile": 260.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 60.75, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 60.75, "10th_percentile": 60.75, "90th_percentile": 60.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 260.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 260.75, "10th_percentile": 260.75, "90th_percentile": 260.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "AMITRIPTYLINE 10 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-432", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "29300-0419-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.73, "maximum": 4.5, "setting": "outpatient", "gross_charge": 4.5, "discounted_cash": 3.15, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "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": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "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": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "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": "DCH BLUE CROSS 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": "DCH 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": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "DCH 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": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH 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": "GLOBAL EXCEL [1712]", "plan_name": "DCH 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": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "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": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 3.11, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 3.11, "10th_percentile": 3.11, "90th_percentile": 3.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 2.21, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.21, "10th_percentile": 2.21, "90th_percentile": 2.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 0.98, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.98, "10th_percentile": 0.98, "90th_percentile": 0.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH 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": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 3.83, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 3.83, "10th_percentile": 3.83, "90th_percentile": 3.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.73, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 0.73, "10th_percentile": 0.73, "90th_percentile": 0.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 3.06, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.06, "10th_percentile": 3.06, "90th_percentile": 3.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 2.13, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.13, "10th_percentile": 2.13, "90th_percentile": 2.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1.3, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2.52, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.52, "10th_percentile": 2.52, "90th_percentile": 2.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1.27, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.27, "10th_percentile": 1.27, "90th_percentile": 1.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1.26, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.26, "10th_percentile": 1.26, "90th_percentile": 1.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 2.37, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.37, "10th_percentile": 2.37, "90th_percentile": 2.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH 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": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 2.93, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% 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 procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 3.38, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 3.38, "10th_percentile": 3.38, "90th_percentile": 3.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 3.38, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 3.38, "10th_percentile": 3.38, "90th_percentile": 3.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 2.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 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 SRVS; 50% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 2.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 4.05, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% 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 SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 4.05, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% 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 SERVICES; 90% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 3.14, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.14, "10th_percentile": 3.14, "90th_percentile": 3.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 3.14, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.14, "10th_percentile": 3.14, "90th_percentile": 3.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH 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": "DCH 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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 1.62, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.62, "10th_percentile": 1.62, "90th_percentile": 1.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 1.62, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.62, "10th_percentile": 1.62, "90th_percentile": 1.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 2.79, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.79, "10th_percentile": 2.79, "90th_percentile": 2.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 2.79, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.79, "10th_percentile": 2.79, "90th_percentile": 2.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH COMPSYCH", "standard_charge_dollar": 3.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 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 DEF; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH 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" } ] } ] }, { "description": "AMITRIPTYLINE 10 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-432", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "50268-0037-15", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.51, "maximum": 9.25, "setting": "outpatient", "gross_charge": 9.25, "discounted_cash": 6.47, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 2.59, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.59, "10th_percentile": 2.59, "90th_percentile": 2.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 5.17, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.17, "10th_percentile": 5.17, "90th_percentile": 5.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 3.33, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 2.62, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.62, "10th_percentile": 2.62, "90th_percentile": 2.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 2.67, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.67, "10th_percentile": 2.67, "90th_percentile": 2.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 6.45, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.45, "10th_percentile": 6.45, "90th_percentile": 6.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 5.74, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.74, "10th_percentile": 5.74, "90th_percentile": 5.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 5.74, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.74, "10th_percentile": 5.74, "90th_percentile": 5.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 8.33, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 8.33, "10th_percentile": 8.33, "90th_percentile": 8.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 8.33, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 8.33, "10th_percentile": 8.33, "90th_percentile": 8.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 7.86, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 7.86, "10th_percentile": 7.86, "90th_percentile": 7.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 6.94, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 6.94, "10th_percentile": 6.94, "90th_percentile": 6.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 6.01, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 6.01, "10th_percentile": 6.01, "90th_percentile": 6.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 4.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 4.63, "10th_percentile": 4.63, "90th_percentile": 4.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 1.51, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 1.51, "10th_percentile": 1.51, "90th_percentile": 1.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 6.28, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.28, "10th_percentile": 6.28, "90th_percentile": 6.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 6.45, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.45, "10th_percentile": 6.45, "90th_percentile": 6.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 3.33, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 4.53, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.53, "10th_percentile": 4.53, "90th_percentile": 4.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 4.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.63, "10th_percentile": 4.63, "90th_percentile": 4.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 9.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 9.25, "10th_percentile": 9.25, "90th_percentile": 9.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 7.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 7.4, "10th_percentile": 7.4, "90th_percentile": 7.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 4.38, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.38, "10th_percentile": 4.38, "90th_percentile": 4.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 5.83, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 5.83, "10th_percentile": 5.83, "90th_percentile": 5.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 6.38, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% 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 Outpatient Services; 69% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 5.94, "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": 5.94, "10th_percentile": 5.94, "90th_percentile": 5.94, "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": "DCH PHCS", "standard_charge_dollar": 6.94, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 6.94, "10th_percentile": 6.94, "90th_percentile": 6.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 2.02, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 7.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 7.4, "10th_percentile": 7.4, "90th_percentile": 7.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 9.25, "10th_percentile": 9.25, "90th_percentile": 9.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 9.25, "10th_percentile": 9.25, "90th_percentile": 9.25, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 9.25, "10th_percentile": 9.25, "90th_percentile": 9.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 9.25, "10th_percentile": 9.25, "90th_percentile": 9.25, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 9.25, "10th_percentile": 9.25, "90th_percentile": 9.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 9.25, "10th_percentile": 9.25, "90th_percentile": 9.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 9.25, "10th_percentile": 9.25, "90th_percentile": 9.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 9.25, "10th_percentile": 9.25, "90th_percentile": 9.25, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 9.25, "10th_percentile": 9.25, "90th_percentile": 9.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 9.25, "10th_percentile": 9.25, "90th_percentile": 9.25, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 9.25, "10th_percentile": 9.25, "90th_percentile": 9.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 4.87, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.87, "10th_percentile": 4.87, "90th_percentile": 4.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 9.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 9.25, "10th_percentile": 9.25, "90th_percentile": 9.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" } ] } ] }, { "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": 1.39, "maximum": 8.5, "setting": "outpatient", "gross_charge": 8.5, "discounted_cash": 5.95, "payers_information": [ { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8.5, "10th_percentile": 8.5, "90th_percentile": 8.5, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8.5, "10th_percentile": 8.5, "90th_percentile": 8.5, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8.5, "10th_percentile": 8.5, "90th_percentile": 8.5, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8.5, "10th_percentile": 8.5, "90th_percentile": 8.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8.5, "10th_percentile": 8.5, "90th_percentile": 8.5, "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": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 4.75, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 5.93, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.93, "10th_percentile": 5.93, "90th_percentile": 5.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 2.45, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.45, "10th_percentile": 2.45, "90th_percentile": 2.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 3.06, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.06, "10th_percentile": 3.06, "90th_percentile": 3.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 2.38, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 2.4, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.4, "10th_percentile": 2.4, "90th_percentile": 2.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 5.27, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.27, "10th_percentile": 5.27, "90th_percentile": 5.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 7.65, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 7.65, "10th_percentile": 7.65, "90th_percentile": 7.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 5.77, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.77, "10th_percentile": 5.77, "90th_percentile": 5.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 5.93, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.93, "10th_percentile": 5.93, "90th_percentile": 5.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 3.06, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.06, "10th_percentile": 3.06, "90th_percentile": 3.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 1.39, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 1.39, "10th_percentile": 1.39, "90th_percentile": 1.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 4.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.25, "10th_percentile": 4.25, "90th_percentile": 4.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 5.27, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.27, "10th_percentile": 5.27, "90th_percentile": 5.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 7.65, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 7.65, "10th_percentile": 7.65, "90th_percentile": 7.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 7.23, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 7.23, "10th_percentile": 7.23, "90th_percentile": 7.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 6.38, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% 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 SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 5.53, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 5.53, "10th_percentile": 5.53, "90th_percentile": 5.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 4.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 4.25, "10th_percentile": 4.25, "90th_percentile": 4.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 4.17, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.17, "10th_percentile": 4.17, "90th_percentile": 4.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 8.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 8.5, "10th_percentile": 8.5, "90th_percentile": 8.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 6.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 6.8, "10th_percentile": 6.8, "90th_percentile": 6.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 4.48, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.48, "10th_percentile": 4.48, "90th_percentile": 4.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 4.03, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.03, "10th_percentile": 4.03, "90th_percentile": 4.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 5.36, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 5.36, "10th_percentile": 5.36, "90th_percentile": 5.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 5.87, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 5.87, "10th_percentile": 5.87, "90th_percentile": 5.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 5.46, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 5.46, "10th_percentile": 5.46, "90th_percentile": 5.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 6.38, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 6.38, "10th_percentile": 6.38, "90th_percentile": 6.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 1.85, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 8.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 8.5, "10th_percentile": 8.5, "90th_percentile": 8.5, "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": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 6.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 6.8, "10th_percentile": 6.8, "90th_percentile": 6.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 8.5, "10th_percentile": 8.5, "90th_percentile": 8.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8.5, "10th_percentile": 8.5, "90th_percentile": 8.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8.5, "10th_percentile": 8.5, "90th_percentile": 8.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8.5, "10th_percentile": 8.5, "90th_percentile": 8.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8.5, "10th_percentile": 8.5, "90th_percentile": 8.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8.5, "10th_percentile": 8.5, "90th_percentile": 8.5, "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": 34.68, "maximum": 212.75, "setting": "outpatient", "gross_charge": 212.75, "discounted_cash": 148.92, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 212.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 212.75, "10th_percentile": 212.75, "90th_percentile": 212.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 112.12, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 112.12, "10th_percentile": 112.12, "90th_percentile": 112.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 212.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 212.75, "10th_percentile": 212.75, "90th_percentile": 212.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 159.56, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 159.56, "10th_percentile": 159.56, "90th_percentile": 159.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 100.84, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 100.84, "10th_percentile": 100.84, "90th_percentile": 100.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 136.65, "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": 136.65, "10th_percentile": 136.65, "90th_percentile": 136.65, "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": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 134.03, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 134.03, "10th_percentile": 134.03, "90th_percentile": 134.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 106.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 106.38, "10th_percentile": 106.38, "90th_percentile": 106.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 180.84, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 180.84, "10th_percentile": 180.84, "90th_percentile": 180.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 138.29, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 138.29, "10th_percentile": 138.29, "90th_percentile": 138.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 191.48, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 191.48, "10th_percentile": 191.48, "90th_percentile": 191.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 212.75, "10th_percentile": 212.75, "90th_percentile": 212.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 212.75, "10th_percentile": 212.75, "90th_percentile": 212.75, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 212.75, "10th_percentile": 212.75, "90th_percentile": 212.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 76.68, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 76.68, "10th_percentile": 76.68, "90th_percentile": 76.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 76.68, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 76.68, "10th_percentile": 76.68, "90th_percentile": 76.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 131.91, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 131.91, "10th_percentile": 131.91, "90th_percentile": 131.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 131.91, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 131.91, "10th_percentile": 131.91, "90th_percentile": 131.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 148.33, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 148.33, "10th_percentile": 148.33, "90th_percentile": 148.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 148.33, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 148.33, "10th_percentile": 148.33, "90th_percentile": 148.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 191.48, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 191.48, "10th_percentile": 191.48, "90th_percentile": 191.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 144.46, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 144.46, "10th_percentile": 144.46, "90th_percentile": 144.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 34.68, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 34.68, "10th_percentile": 34.68, "90th_percentile": 34.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 106.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 106.38, "10th_percentile": 106.38, "90th_percentile": 106.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 146.8, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 146.8, "10th_percentile": 146.8, "90th_percentile": 146.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 170.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 170.2, "10th_percentile": 170.2, "90th_percentile": 170.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 46.38, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 46.38, "10th_percentile": 46.38, "90th_percentile": 46.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 104.25, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 104.25, "10th_percentile": 104.25, "90th_percentile": 104.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 170.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 170.2, "10th_percentile": 170.2, "90th_percentile": 170.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 159.56, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 159.56, "10th_percentile": 159.56, "90th_percentile": 159.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 118.93, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 118.93, "10th_percentile": 118.93, "90th_percentile": 118.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 60.17, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 60.17, "10th_percentile": 60.17, "90th_percentile": 60.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 59.57, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 59.57, "10th_percentile": 59.57, "90th_percentile": 59.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 61.36, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 61.36, "10th_percentile": 61.36, "90th_percentile": 61.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 212.75, "10th_percentile": 212.75, "90th_percentile": 212.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 212.75, "10th_percentile": 212.75, "90th_percentile": 212.75, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 212.75, "10th_percentile": 212.75, "90th_percentile": 212.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 212.75, "10th_percentile": 212.75, "90th_percentile": 212.75, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 212.75, "10th_percentile": 212.75, "90th_percentile": 212.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 212.75, "10th_percentile": 212.75, "90th_percentile": 212.75, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 212.75, "10th_percentile": 212.75, "90th_percentile": 212.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 212.75, "10th_percentile": 212.75, "90th_percentile": 212.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "AMPICILLIN SODIUM 1 G INJ SOLR", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-27280", "type": "CDM" }, { "code": "J0290", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "00781-9404-85", "type": "NDC" } ], "standard_charges": [ { "minimum": 22.69, "maximum": 152.25, "setting": "outpatient", "gross_charge": 152.25, "discounted_cash": 106.57, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 152.25, "10th_percentile": 152.25, "90th_percentile": 152.25, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 152.25, "10th_percentile": 152.25, "90th_percentile": 152.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 152.25, "10th_percentile": 152.25, "90th_percentile": 152.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 152.25, "10th_percentile": 152.25, "90th_percentile": 152.25, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 152.25, "10th_percentile": 152.25, "90th_percentile": 152.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 152.25, "10th_percentile": 152.25, "90th_percentile": 152.25, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 152.25, "10th_percentile": 152.25, "90th_percentile": 152.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $152.25 @ 6.8% = $10.35 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": 10.35, "10th_percentile": 10.35, "90th_percentile": 10.35, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $152.25 @ 6.8% = $10.35 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": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $152.25 @ 6.8% = $10.35 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": 10.35, "10th_percentile": 10.35, "90th_percentile": 10.35, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $152.25 @ 6.8% = $10.35 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $152.25 @ 6.8% = $10.35 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": 10.35, "10th_percentile": 10.35, "90th_percentile": 10.35, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $152.25 @ 6.8% = $10.35 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": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $152.25 @ 12.5% = $19.03 due to $0.00 Claim Price", "median_amount": 19.03, "10th_percentile": 19.03, "90th_percentile": 19.03, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $152.25 @ 12.5% = $19.03 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 27.41, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 27.41, "10th_percentile": 27.41, "90th_percentile": 27.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 24.82, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 24.82, "10th_percentile": 24.82, "90th_percentile": 24.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 85.11, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 85.11, "10th_percentile": 85.11, "90th_percentile": 85.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 76.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 76.13, "10th_percentile": 76.13, "90th_percentile": 76.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 114.19, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 114.19, "10th_percentile": 114.19, "90th_percentile": 114.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 152.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 152.25, "10th_percentile": 152.25, "90th_percentile": 152.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 105.05, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 105.05, "10th_percentile": 105.05, "90th_percentile": 105.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 121.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 121.8, "10th_percentile": 121.8, "90th_percentile": 121.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 121.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 121.8, "10th_percentile": 121.8, "90th_percentile": 121.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 152.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 152.25, "10th_percentile": 152.25, "90th_percentile": 152.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 95.92, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 95.92, "10th_percentile": 95.92, "90th_percentile": 95.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 129.41, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 129.41, "10th_percentile": 129.41, "90th_percentile": 129.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 76.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 76.13, "10th_percentile": 76.13, "90th_percentile": 76.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 114.19, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 114.19, "10th_percentile": 114.19, "90th_percentile": 114.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 98.96, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 98.96, "10th_percentile": 98.96, "90th_percentile": 98.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 22.69, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 22.69, "10th_percentile": 22.69, "90th_percentile": 22.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 22.69, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 22.69, "10th_percentile": 22.69, "90th_percentile": 22.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 137.03, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 137.03, "10th_percentile": 137.03, "90th_percentile": 137.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 137.03, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 137.03, "10th_percentile": 137.03, "90th_percentile": 137.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 35.47, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 35.47, "10th_percentile": 35.47, "90th_percentile": 35.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 35.47, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 35.47, "10th_percentile": 35.47, "90th_percentile": 35.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 106.15, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 106.15, "10th_percentile": 106.15, "90th_percentile": 106.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 106.15, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 106.15, "10th_percentile": 106.15, "90th_percentile": 106.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "AMPICILLIN SODIUM 500 MG INJ SOLR", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-474", "type": "CDM" }, { "code": "J0290", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "00781-3407-95", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.98, "maximum": 20.0, "setting": "outpatient", "gross_charge": 20.0, "discounted_cash": 14.0, "payers_information": [ { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH 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": "DCH 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": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS 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": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "DCH 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": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "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": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "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": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $20.00 @ 12.5% = $2.50 due to $0.00 Claim Price", "median_amount": 2.5, "10th_percentile": 2.5, "90th_percentile": 2.5, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $20.00 @ 12.5% = $2.50 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $20.00 @ 6.8% = $1.36 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": 1.36, "10th_percentile": 1.36, "90th_percentile": 1.36, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $20.00 @ 6.8% = $1.36 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $20.00 @ 6.8% = $1.36 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": 1.36, "10th_percentile": 1.36, "90th_percentile": 1.36, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $20.00 @ 6.8% = $1.36 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": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $20.00 @ 6.8% = $1.36 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": 1.36, "10th_percentile": 1.36, "90th_percentile": 1.36, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $20.00 @ 6.8% = $1.36 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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 3.6, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.6, "10th_percentile": 3.6, "90th_percentile": 3.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 4.66, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 4.66, "10th_percentile": 4.66, "90th_percentile": 4.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 11.18, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.18, "10th_percentile": 11.18, "90th_percentile": 11.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 13.94, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13.94, "10th_percentile": 13.94, "90th_percentile": 13.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 2.98, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.98, "10th_percentile": 2.98, "90th_percentile": 2.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 2.98, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.98, "10th_percentile": 2.98, "90th_percentile": 2.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 18.0, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 18.0, "10th_percentile": 18.0, "90th_percentile": 18.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 18.0, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 18.0, "10th_percentile": 18.0, "90th_percentile": 18.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 13.0, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 13.0, "10th_percentile": 13.0, "90th_percentile": 13.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 17.0, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 17.0, "10th_percentile": 17.0, "90th_percentile": 17.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 10.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 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 SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 15.0, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 15.0, "10th_percentile": 15.0, "90th_percentile": 15.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 10.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.0, "10th_percentile": 10.0, "90th_percentile": 10.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 13.8, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 13.8, "10th_percentile": 13.8, "90th_percentile": 13.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 13.94, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13.94, "10th_percentile": 13.94, "90th_percentile": 13.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH 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": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 16.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 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 DEF; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH 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": "HEALTHLINK [125]", "plan_name": "DCH 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": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 15.0, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 15.0, "10th_percentile": 15.0, "90th_percentile": 15.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 4.66, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 4.66, "10th_percentile": 4.66, "90th_percentile": 4.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 3.26, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 3.26, "10th_percentile": 3.26, "90th_percentile": 3.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH 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" } ] } ] }, { "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": 10.24, "maximum": 68.75, "setting": "outpatient", "gross_charge": 68.75, "discounted_cash": 48.12, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.75, "10th_percentile": 68.75, "90th_percentile": 68.75, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.75, "10th_percentile": 68.75, "90th_percentile": 68.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.75, "10th_percentile": 68.75, "90th_percentile": 68.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.75, "10th_percentile": 68.75, "90th_percentile": 68.75, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.75, "10th_percentile": 68.75, "90th_percentile": 68.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.75, "10th_percentile": 68.75, "90th_percentile": 68.75, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 68.75, "10th_percentile": 68.75, "90th_percentile": 68.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $68.75 @ 6.8% = $4.68 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": 4.68, "10th_percentile": 4.68, "90th_percentile": 4.68, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $68.75 @ 6.8% = $4.68 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": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $68.75 @ 6.8% = $4.68 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": 4.68, "10th_percentile": 4.68, "90th_percentile": 4.68, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $68.75 @ 6.8% = $4.68 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $68.75 @ 6.8% = $4.68 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": 4.68, "10th_percentile": 4.68, "90th_percentile": 4.68, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $68.75 @ 6.8% = $4.68 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": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $68.75 @ 12.5% = $8.59 due to $0.00 Claim Price", "median_amount": 8.59, "10th_percentile": 8.59, "90th_percentile": 8.59, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $68.75 @ 12.5% = $8.59 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 12.38, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.38, "10th_percentile": 12.38, "90th_percentile": 12.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 11.21, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 11.21, "10th_percentile": 11.21, "90th_percentile": 11.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 38.43, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 38.43, "10th_percentile": 38.43, "90th_percentile": 38.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 34.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 34.38, "10th_percentile": 34.38, "90th_percentile": 34.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 51.56, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 51.56, "10th_percentile": 51.56, "90th_percentile": 51.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 68.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 68.75, "10th_percentile": 68.75, "90th_percentile": 68.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 47.44, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 47.44, "10th_percentile": 47.44, "90th_percentile": 47.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 55.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 55.0, "10th_percentile": 55.0, "90th_percentile": 55.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 55.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 55.0, "10th_percentile": 55.0, "90th_percentile": 55.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 68.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 68.75, "10th_percentile": 68.75, "90th_percentile": 68.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 43.31, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 43.31, "10th_percentile": 43.31, "90th_percentile": 43.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 58.44, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 58.44, "10th_percentile": 58.44, "90th_percentile": 58.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 34.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 34.38, "10th_percentile": 34.38, "90th_percentile": 34.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 51.56, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 51.56, "10th_percentile": 51.56, "90th_percentile": 51.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 44.69, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 44.69, "10th_percentile": 44.69, "90th_percentile": 44.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 10.24, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.24, "10th_percentile": 10.24, "90th_percentile": 10.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 10.24, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.24, "10th_percentile": 10.24, "90th_percentile": 10.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 61.88, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 61.88, "10th_percentile": 61.88, "90th_percentile": 61.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 61.88, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 61.88, "10th_percentile": 61.88, "90th_percentile": 61.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 16.02, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 16.02, "10th_percentile": 16.02, "90th_percentile": 16.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 16.02, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 16.02, "10th_percentile": 16.02, "90th_percentile": 16.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 47.93, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 47.93, "10th_percentile": 47.93, "90th_percentile": 47.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 47.93, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 47.93, "10th_percentile": 47.93, "90th_percentile": 47.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "AMPLATZER PLUG VASC OCCL 6X7MM NIT", "code_information": [ { "code": "SUP-112018", "type": "CDM" }, { "code": "C1889", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 1051.52, "maximum": 7158.06, "setting": "outpatient", "gross_charge": 7158.06, "discounted_cash": 5010.64, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $7,158.06 @ 6.8% = $486.75 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": 1962.13, "10th_percentile": 1962.13, "90th_percentile": 1962.13, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $7,158.06 @ 6.8% = $486.75 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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $7,158.06 @ 6.8% = $486.75 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": 1962.13, "10th_percentile": 1962.13, "90th_percentile": 1962.13, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $7,158.06 @ 6.8% = $486.75 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": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $7,158.06 @ 6.8% = $486.75 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": 1962.13, "10th_percentile": 1962.13, "90th_percentile": 1962.13, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $7,158.06 @ 6.8% = $486.75 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": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 3772.3, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 81.76, "10th_percentile": 81.76, "90th_percentile": 81.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 7158.06, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 7158.06, "10th_percentile": 7158.06, "90th_percentile": 7158.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7158.06, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7158.06, "10th_percentile": 7158.06, "90th_percentile": 7158.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 4597.62, "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": 4597.62, "10th_percentile": 4597.62, "90th_percentile": 4597.62, "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": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 4939.06, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 4939.06, "10th_percentile": 4939.06, "90th_percentile": 4939.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1288.45, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1288.45, "10th_percentile": 1288.45, "90th_percentile": 1288.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 3579.03, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3579.03, "10th_percentile": 3579.03, "90th_percentile": 3579.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 5726.45, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 5726.45, "10th_percentile": 5726.45, "90th_percentile": 5726.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 5368.55, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 5368.55, "10th_percentile": 5368.55, "90th_percentile": 5368.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 4509.58, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 4509.58, "10th_percentile": 4509.58, "90th_percentile": 4509.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 4001.36, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4001.36, "10th_percentile": 4001.36, "90th_percentile": 4001.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 3507.45, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3507.45, "10th_percentile": 3507.45, "90th_percentile": 3507.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 1166.76, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 1166.76, "10th_percentile": 1166.76, "90th_percentile": 1166.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 3392.92, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3392.92, "10th_percentile": 3392.92, "90th_percentile": 3392.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 1560.46, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1560.46, "10th_percentile": 1560.46, "90th_percentile": 1560.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 5726.45, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 5726.45, "10th_percentile": 5726.45, "90th_percentile": 5726.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 6084.35, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 6084.35, "10th_percentile": 6084.35, "90th_percentile": 6084.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 3579.03, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 3579.03, "10th_percentile": 3579.03, "90th_percentile": 3579.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 4652.74, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 4652.74, "10th_percentile": 4652.74, "90th_percentile": 4652.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 5368.55, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 5368.55, "10th_percentile": 5368.55, "90th_percentile": 5368.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 6442.25, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 6442.25, "10th_percentile": 6442.25, "90th_percentile": 6442.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 6442.25, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 6442.25, "10th_percentile": 6442.25, "90th_percentile": 6442.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1066.55, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1066.55, "10th_percentile": 1066.55, "90th_percentile": 1066.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1066.55, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1066.55, "10th_percentile": 1066.55, "90th_percentile": 1066.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 4990.6, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4990.6, "10th_percentile": 4990.6, "90th_percentile": 4990.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 4990.6, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4990.6, "10th_percentile": 4990.6, "90th_percentile": 4990.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 1667.83, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 1667.83, "10th_percentile": 1667.83, "90th_percentile": 1667.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 1667.83, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 1667.83, "10th_percentile": 1667.83, "90th_percentile": 1667.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 1051.52, "standard_charge_percentage": 14.69, "standard_charge_algorithm": "Implant/Prosthetic Rev Code 278; 14.69% Billed", "median_amount": 1051.52, "10th_percentile": 1051.52, "90th_percentile": 1051.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Implant/Prosthetic Rev Code 278; 14.69% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 1051.52, "standard_charge_percentage": 14.69, "standard_charge_algorithm": "Implant/Prosthetic Rev Code 278; 14.69% Billed", "median_amount": 1051.52, "10th_percentile": 1051.52, "90th_percentile": 1051.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Implant/Prosthetic Rev Code 278; 14.69% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 1051.52, "standard_charge_percentage": 14.69, "standard_charge_algorithm": "Implant/Prosthetic Rev Code 278; 14.69% Billed", "median_amount": 1051.52, "10th_percentile": 1051.52, "90th_percentile": 1051.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Implant/Prosthetic Rev Code 278; 14.69% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $7,158.06 @ 12.5% = $894.76 due to $0.00 Claim Price", "median_amount": 894.76, "10th_percentile": 894.76, "90th_percentile": 894.76, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $7,158.06 @ 12.5% = $894.76 due to $0.00 Claim Price" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 7158.06, "10th_percentile": 7158.06, "90th_percentile": 7158.06, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 7158.06, "10th_percentile": 7158.06, "90th_percentile": 7158.06, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 7158.06, "10th_percentile": 7158.06, "90th_percentile": 7158.06, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 7158.06, "10th_percentile": 7158.06, "90th_percentile": 7158.06, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 7158.06, "10th_percentile": 7158.06, "90th_percentile": 7158.06, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 7158.06, "10th_percentile": 7158.06, "90th_percentile": 7158.06, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 7158.06, "10th_percentile": 7158.06, "90th_percentile": 7158.06, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "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": 1699.76, "maximum": 11570.89, "setting": "outpatient", "gross_charge": 11570.89, "discounted_cash": 8099.62, "payers_information": [ { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $11,570.89 @ 6.8% = $786.82 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": 437.89, "10th_percentile": 437.89, "90th_percentile": 437.89, "count": "15", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $11,570.89 @ 6.8% = $786.82 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": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $11,570.89 @ 6.8% = $786.82 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": 437.89, "10th_percentile": 437.89, "90th_percentile": 437.89, "count": "15", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $11,570.89 @ 6.8% = $786.82 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $11,570.89 @ 6.8% = $786.82 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": 437.89, "10th_percentile": 437.89, "90th_percentile": 437.89, "count": "15", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $11,570.89 @ 6.8% = $786.82 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": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 6097.86, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 666.22, "10th_percentile": 666.22, "90th_percentile": 666.22, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 1886.06, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 886.16, "10th_percentile": 886.16, "90th_percentile": 886.16, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 10413.8, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 10413.8, "10th_percentile": 10413.8, "90th_percentile": 10413.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 10413.8, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 10413.8, "10th_percentile": 10413.8, "90th_percentile": 10413.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 2696.02, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 2696.02, "10th_percentile": 2696.02, "90th_percentile": 2696.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 2696.02, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 2696.02, "10th_percentile": 2696.02, "90th_percentile": 2696.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 2082.76, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2082.76, "10th_percentile": 2082.76, "90th_percentile": 2082.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 6468.13, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6468.13, "10th_percentile": 6468.13, "90th_percentile": 6468.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 5785.45, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5785.45, "10th_percentile": 5785.45, "90th_percentile": 5785.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 11570.89, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 11570.89, "10th_percentile": 11570.89, "90th_percentile": 11570.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 7983.91, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 7983.91, "10th_percentile": 7983.91, "90th_percentile": 7983.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 8678.17, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 8678.17, "10th_percentile": 8678.17, "90th_percentile": 8678.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 9256.71, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 9256.71, "10th_percentile": 9256.71, "90th_percentile": 9256.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 9256.71, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 9256.71, "10th_percentile": 9256.71, "90th_percentile": 9256.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 5484.6, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5484.6, "10th_percentile": 5484.6, "90th_percentile": 5484.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 7289.66, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 7289.66, "10th_percentile": 7289.66, "90th_percentile": 7289.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 7431.98, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 7431.98, "10th_percentile": 7431.98, "90th_percentile": 7431.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 2522.45, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2522.45, "10th_percentile": 2522.45, "90th_percentile": 2522.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 11570.89, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 11570.89, "10th_percentile": 11570.89, "90th_percentile": 11570.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 5669.74, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1137.43, "10th_percentile": 1137.43, "90th_percentile": 1137.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 8678.17, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 8678.17, "10th_percentile": 8678.17, "90th_percentile": 8678.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 9835.26, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 9835.26, "10th_percentile": 9835.26, "90th_percentile": 9835.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 7521.08, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 7521.08, "10th_percentile": 7521.08, "90th_percentile": 7521.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 5785.45, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 5785.45, "10th_percentile": 5785.45, "90th_percentile": 5785.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1724.06, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1724.06, "10th_percentile": 1724.06, "90th_percentile": 1724.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1724.06, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1724.06, "10th_percentile": 1724.06, "90th_percentile": 1724.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 8067.22, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8067.22, "10th_percentile": 8067.22, "90th_percentile": 8067.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 8067.22, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8067.22, "10th_percentile": 8067.22, "90th_percentile": 8067.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 1699.76, "standard_charge_percentage": 14.69, "standard_charge_algorithm": "Implant/Prosthetic Rev Code 278; 14.69% Billed", "median_amount": 1699.76, "10th_percentile": 1699.76, "90th_percentile": 1699.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Implant/Prosthetic Rev Code 278; 14.69% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 1699.76, "standard_charge_percentage": 14.69, "standard_charge_algorithm": "Implant/Prosthetic Rev Code 278; 14.69% Billed", "median_amount": 1699.76, "10th_percentile": 1699.76, "90th_percentile": 1699.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Implant/Prosthetic Rev Code 278; 14.69% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 1699.76, "standard_charge_percentage": 14.69, "standard_charge_algorithm": "Implant/Prosthetic Rev Code 278; 14.69% Billed", "median_amount": 1699.76, "10th_percentile": 1699.76, "90th_percentile": 1699.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Implant/Prosthetic Rev Code 278; 14.69% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $11,570.89 @ 12.5% = $1,446.36 due to $0.00 Claim Price", "median_amount": 1446.36, "10th_percentile": 1446.36, "90th_percentile": 1446.36, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $11,570.89 @ 12.5% = $1,446.36 due to $0.00 Claim Price" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 11570.89, "10th_percentile": 11570.89, "90th_percentile": 11570.89, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11570.89, "10th_percentile": 11570.89, "90th_percentile": 11570.89, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11570.89, "10th_percentile": 11570.89, "90th_percentile": 11570.89, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11570.89, "10th_percentile": 11570.89, "90th_percentile": 11570.89, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11570.89, "10th_percentile": 11570.89, "90th_percentile": 11570.89, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11570.89, "10th_percentile": 11570.89, "90th_percentile": 11570.89, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11570.89, "10th_percentile": 11570.89, "90th_percentile": 11570.89, "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": 20.52, "maximum": 125.86, "setting": "outpatient", "gross_charge": 125.86, "discounted_cash": 88.1, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 78.03, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 78.03, "10th_percentile": 78.03, "90th_percentile": 78.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 78.03, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 78.03, "10th_percentile": 78.03, "90th_percentile": 78.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 36.3, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 36.3, "10th_percentile": 36.3, "90th_percentile": 36.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 87.75, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 87.75, "10th_percentile": 87.75, "90th_percentile": 87.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 35.59, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 35.59, "10th_percentile": 35.59, "90th_percentile": 35.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 70.36, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 70.36, "10th_percentile": 70.36, "90th_percentile": 70.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 45.36, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 45.36, "10th_percentile": 45.36, "90th_percentile": 45.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 35.24, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 35.24, "10th_percentile": 35.24, "90th_percentile": 35.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 113.27, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 113.27, "10th_percentile": 113.27, "90th_percentile": 113.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 113.27, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 113.27, "10th_percentile": 113.27, "90th_percentile": 113.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 62.93, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 62.93, "10th_percentile": 62.93, "90th_percentile": 62.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 81.81, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 81.81, "10th_percentile": 81.81, "90th_percentile": 81.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 94.4, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 94.4, "10th_percentile": 94.4, "90th_percentile": 94.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 106.98, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 106.98, "10th_percentile": 106.98, "90th_percentile": 106.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 85.46, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 85.46, "10th_percentile": 85.46, "90th_percentile": 85.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 125.86, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 125.86, "10th_percentile": 125.86, "90th_percentile": 125.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 100.69, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 100.69, "10th_percentile": 100.69, "90th_percentile": 100.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 59.66, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 59.66, "10th_percentile": 59.66, "90th_percentile": 59.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 66.33, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 66.33, "10th_percentile": 66.33, "90th_percentile": 66.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 125.86, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 125.86, "10th_percentile": 125.86, "90th_percentile": 125.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 80.84, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 80.84, "10th_percentile": 80.84, "90th_percentile": 80.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 94.4, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 94.4, "10th_percentile": 94.4, "90th_percentile": 94.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 27.44, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 27.44, "10th_percentile": 27.44, "90th_percentile": 27.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 100.69, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 100.69, "10th_percentile": 100.69, "90th_percentile": 100.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 61.67, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 61.67, "10th_percentile": 61.67, "90th_percentile": 61.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 62.93, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 62.93, "10th_percentile": 62.93, "90th_percentile": 62.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 87.75, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 87.75, "10th_percentile": 87.75, "90th_percentile": 87.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 86.84, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 86.84, "10th_percentile": 86.84, "90th_percentile": 86.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 20.52, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 20.52, "10th_percentile": 20.52, "90th_percentile": 20.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 45.36, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 45.36, "10th_percentile": 45.36, "90th_percentile": 45.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 79.29, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 79.29, "10th_percentile": 79.29, "90th_percentile": 79.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 125.86, "10th_percentile": 125.86, "90th_percentile": 125.86, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 125.86, "10th_percentile": 125.86, "90th_percentile": 125.86, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 125.86, "10th_percentile": 125.86, "90th_percentile": 125.86, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 125.86, "10th_percentile": 125.86, "90th_percentile": 125.86, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 125.86, "10th_percentile": 125.86, "90th_percentile": 125.86, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 125.86, "10th_percentile": 125.86, "90th_percentile": 125.86, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 125.86, "10th_percentile": 125.86, "90th_percentile": 125.86, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 125.86, "10th_percentile": 125.86, "90th_percentile": 125.86, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 125.86, "10th_percentile": 125.86, "90th_percentile": 125.86, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 125.86, "10th_percentile": 125.86, "90th_percentile": 125.86, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 125.86, "10th_percentile": 125.86, "90th_percentile": 125.86, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "APPENDIX PROCEDURES WITHOUT CC/MCC", "code_information": [ { "code": "399", "type": "MS-DRG" } ], "standard_charges": [ { "minimum": 8145.49, "maximum": 17842.44, "setting": "inpatient", "gross_charge": 66218.34, "discounted_cash": 46352.84, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.791586065; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services; 100% Billed", "median_amount": 66207.1, "10th_percentile": 66207.1, "90th_percentile": 66207.1, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.791586065; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services - OON; 100% Billed", "median_amount": 66207.1, "10th_percentile": 66207.1, "90th_percentile": 66207.1, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.791586065; Using historical claim(s); Scope: All Financial Classes; Cases: 4; Inpatient (Non Covered - Verify Coverage); 100% Billed", "median_amount": 66207.1, "10th_percentile": 66207.1, "90th_percentile": 66207.1, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 49655.34, "10th_percentile": 49655.34, "90th_percentile": 49655.34, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH 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": 33103.6, "10th_percentile": 33103.6, "90th_percentile": 33103.6, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_percentage": 65.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 43034.62, "10th_percentile": 43034.62, "90th_percentile": 43034.62, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_percentage": 85.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 56276.03, "10th_percentile": 56276.03, "90th_percentile": 56276.03, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_percentage": 49.0, "standard_charge_algorithm": "Re-evaluated: HLB.791586065; Using historical claim(s); Scope: All Financial Classes; Cases: 4; IP Services. ADP RATE (for patient estimates only); 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 32441.48, "10th_percentile": 32441.48, "90th_percentile": 32441.48, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_percentage": 90.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 59586.42, "10th_percentile": 59586.42, "90th_percentile": 59586.42, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_percentage": 67.8, "standard_charge_algorithm": "Re-evaluated: HLB.791586065; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All Inpatient Services; 67.8% Billed", "median_amount": 44888.41, "10th_percentile": 44888.41, "90th_percentile": 44888.41, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Re-evaluated: HLB.791586065; Using historical claim(s); Scope: All Financial Classes; Cases: 4; Inpatient Services; 63% Billed", "median_amount": 41710.47, "10th_percentile": 41710.47, "90th_percentile": 41710.47, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH 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": 52965.66, "10th_percentile": 52965.66, "90th_percentile": 52965.66, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 17842.44, "standard_charge_algorithm": "Re-evaluated: HLB.791586065; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1447, Rate: 15,587.00, and; Pricing Extension - NM HB XR PRC - DCH 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": 17842.44, "10th_percentile": 17842.44, "90th_percentile": 17842.44, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 8609.29, "standard_charge_algorithm": "Re-evaluated: HLB.791586065; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1447, Rate: 7,521.00, and; Pricing Extension - NM HB XR PRC - DCH 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": 8609.29, "10th_percentile": 8609.29, "90th_percentile": 8609.29, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_dollar": 8145.49, "standard_charge_algorithm": "Re-evaluated: HLB.791586065; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All DRGs (Plans excl O-IME); FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.14, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALCULATION EXCL O-IME; Note: Base payment: $8,847.80; Total: $8,847.80", "median_amount": 8847.8, "10th_percentile": 8847.8, "90th_percentile": 8847.8, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.791586065; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All DRGs (Plans excl O-IME); FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.14, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALCULATION EXCL O-IME; Note: Base payment: $8,847.80; Total: $8,847.80" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_percentage": 16.3, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 11786.03, "10th_percentile": 11786.03, "90th_percentile": 11786.03, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_percentage": 90.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 59586.42, "10th_percentile": 59586.42, "90th_percentile": 59586.42, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 17842.44, "standard_charge_algorithm": "Re-evaluated: HLB.791586065; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1447, Rate: 15,587.00, and; Pricing Extension - NM HB XR PRC - DCH 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": 17842.44, "10th_percentile": 17842.44, "90th_percentile": 17842.44, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 8609.29, "standard_charge_algorithm": "Re-evaluated: HLB.791586065; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1447, Rate: 7,521.00, and; Pricing Extension - NM HB XR PRC - DCH 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": 8609.29, "10th_percentile": 8609.29, "90th_percentile": 8609.29, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 10280.55, "standard_charge_algorithm": "Re-evaluated: HLB.791586065; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1447, Rate: 8,981.00, and; Pricing Extension - NM HB XR PRC - DCH 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": 10280.55, "10th_percentile": 10280.55, "90th_percentile": 10280.55, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 8495.96, "standard_charge_algorithm": "Re-evaluated: HLB.791586065; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1447, Rate: 7,422.00, and; Pricing Extension - NM HB XR PRC - DCH BCBS CHOICE SELECT CASE RATE W/OUTLIER S*", "median_amount": 8495.96, "10th_percentile": 8495.96, "90th_percentile": 8495.96, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 8666.52, "standard_charge_algorithm": "Re-evaluated: HLB.791586065; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1447, Rate: 7,571.00, and; Pricing Extension - NM HB XR PRC - DCH 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": 8666.52, "10th_percentile": 8666.52, "90th_percentile": 8666.52, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "DCH HUMANA MEDICARE ADVT", "standard_charge_dollar": 8145.49, "standard_charge_algorithm": "Re-evaluated: HLB.791586065; Using historical claim(s); Scope: All Financial Classes; Cases: 4; 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: $8,792.99; Total: $8,792.99 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8792.99, "10th_percentile": 8792.99, "90th_percentile": 8792.99, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.791586065; Using historical claim(s); Scope: All Financial Classes; Cases: 4; 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: $8,792.99; Total: $8,792.99 Paid at contractual rate, which is the lesser 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": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_dollar": 8145.49, "standard_charge_algorithm": "Re-evaluated: HLB.791586065; Using historical claim(s); Scope: All Financial Classes; Cases: 4; 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: $8,847.80; Percentage applied: 97.00%; Total: $8,582.37 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8582.37, "10th_percentile": 8582.37, "90th_percentile": 8582.37, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.791586065; Using historical claim(s); Scope: All Financial Classes; Cases: 4; 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: $8,847.80; Percentage applied: 97.00%; Total: $8,582.37 Paid at contractual rate, which is the lesser of contractual and 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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 8145.49, "standard_charge_algorithm": "Re-evaluated: HLB.791586065; Using historical claim(s); Scope: All Financial Classes; Cases: 4; 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: $8,847.80; Total: $8,847.80 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": 8847.8, "10th_percentile": 8847.8, "90th_percentile": 8847.8, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.791586065; Using historical claim(s); Scope: All Financial Classes; Cases: 4; 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: $8,847.80; Total: $8,847.80 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." } ] } ] }, { "description": "ARTERIAL LINE TRANSDUCER SINGLE", "code_information": [ { "code": "SUP-303387", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 18.46, "maximum": 113.27, "setting": "outpatient", "gross_charge": 113.27, "discounted_cash": 79.29, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 32.03, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 32.03, "10th_percentile": 32.03, "90th_percentile": 32.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 31.72, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 31.72, "10th_percentile": 31.72, "90th_percentile": 31.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 63.32, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 63.32, "10th_percentile": 63.32, "90th_percentile": 63.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 40.82, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 40.82, "10th_percentile": 40.82, "90th_percentile": 40.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 78.97, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 78.97, "10th_percentile": 78.97, "90th_percentile": 78.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 32.67, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 32.67, "10th_percentile": 32.67, "90th_percentile": 32.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 101.94, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 101.94, "10th_percentile": 101.94, "90th_percentile": 101.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 101.94, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 101.94, "10th_percentile": 101.94, "90th_percentile": 101.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 113.27, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 113.27, "10th_percentile": 113.27, "90th_percentile": 113.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 84.95, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 84.95, "10th_percentile": 84.95, "90th_percentile": 84.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 76.91, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 76.91, "10th_percentile": 76.91, "90th_percentile": 76.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH THE ALLIANCE", "standard_charge_dollar": 72.75, "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": 72.75, "10th_percentile": 72.75, "90th_percentile": 72.75, "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": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 56.64, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 56.64, "10th_percentile": 56.64, "90th_percentile": 56.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 78.16, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 78.16, "10th_percentile": 78.16, "90th_percentile": 78.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 78.97, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 78.97, "10th_percentile": 78.97, "90th_percentile": 78.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH COMPSYCH", "standard_charge_dollar": 90.62, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 90.62, "10th_percentile": 90.62, "90th_percentile": 90.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 18.46, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 18.46, "10th_percentile": 18.46, "90th_percentile": 18.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 71.36, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 71.36, "10th_percentile": 71.36, "90th_percentile": 71.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 40.82, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 40.82, "10th_percentile": 40.82, "90th_percentile": 40.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 24.69, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 24.69, "10th_percentile": 24.69, "90th_percentile": 24.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 55.5, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 55.5, "10th_percentile": 55.5, "90th_percentile": 55.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 90.62, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 90.62, "10th_percentile": 90.62, "90th_percentile": 90.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 113.27, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 113.27, "10th_percentile": 113.27, "90th_percentile": 113.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 59.69, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 59.69, "10th_percentile": 59.69, "90th_percentile": 59.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 53.69, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 53.69, "10th_percentile": 53.69, "90th_percentile": 53.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 96.28, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 96.28, "10th_percentile": 96.28, "90th_percentile": 96.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 56.64, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% 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 OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 84.95, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 84.95, "10th_percentile": 84.95, "90th_percentile": 84.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 73.63, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 73.63, "10th_percentile": 73.63, "90th_percentile": 73.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 70.23, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 70.23, "10th_percentile": 70.23, "90th_percentile": 70.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 70.23, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 70.23, "10th_percentile": 70.23, "90th_percentile": 70.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 113.27, "10th_percentile": 113.27, "90th_percentile": 113.27, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 113.27, "10th_percentile": 113.27, "90th_percentile": 113.27, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 113.27, "10th_percentile": 113.27, "90th_percentile": 113.27, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 113.27, "10th_percentile": 113.27, "90th_percentile": 113.27, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 113.27, "10th_percentile": 113.27, "90th_percentile": 113.27, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 113.27, "10th_percentile": 113.27, "90th_percentile": 113.27, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 113.27, "10th_percentile": 113.27, "90th_percentile": 113.27, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 113.27, "10th_percentile": 113.27, "90th_percentile": 113.27, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 113.27, "10th_percentile": 113.27, "90th_percentile": 113.27, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 113.27, "10th_percentile": 113.27, "90th_percentile": 113.27, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 113.27, "10th_percentile": 113.27, "90th_percentile": 113.27, "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": 53.4, "maximum": 327.59, "setting": "outpatient", "gross_charge": 327.59, "discounted_cash": 229.31, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 92.64, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 92.64, "10th_percentile": 92.64, "90th_percentile": 92.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 91.73, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 91.73, "10th_percentile": 91.73, "90th_percentile": 91.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 183.12, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 183.12, "10th_percentile": 183.12, "90th_percentile": 183.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 118.06, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 118.06, "10th_percentile": 118.06, "90th_percentile": 118.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 228.4, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 228.4, "10th_percentile": 228.4, "90th_percentile": 228.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 94.48, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 94.48, "10th_percentile": 94.48, "90th_percentile": 94.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 294.83, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 294.83, "10th_percentile": 294.83, "90th_percentile": 294.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 294.83, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 294.83, "10th_percentile": 294.83, "90th_percentile": 294.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 327.59, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 327.59, "10th_percentile": 327.59, "90th_percentile": 327.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 245.69, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 245.69, "10th_percentile": 245.69, "90th_percentile": 245.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 222.43, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 222.43, "10th_percentile": 222.43, "90th_percentile": 222.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH THE ALLIANCE", "standard_charge_dollar": 210.41, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 210.41, "10th_percentile": 210.41, "90th_percentile": 210.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 163.8, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 163.8, "10th_percentile": 163.8, "90th_percentile": 163.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 226.04, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 226.04, "10th_percentile": 226.04, "90th_percentile": 226.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 228.4, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 228.4, "10th_percentile": 228.4, "90th_percentile": 228.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH COMPSYCH", "standard_charge_dollar": 262.07, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 262.07, "10th_percentile": 262.07, "90th_percentile": 262.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 53.4, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 53.4, "10th_percentile": 53.4, "90th_percentile": 53.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 206.38, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 206.38, "10th_percentile": 206.38, "90th_percentile": 206.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 118.06, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 118.06, "10th_percentile": 118.06, "90th_percentile": 118.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 71.41, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 71.41, "10th_percentile": 71.41, "90th_percentile": 71.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 160.52, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 160.52, "10th_percentile": 160.52, "90th_percentile": 160.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 262.07, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 262.07, "10th_percentile": 262.07, "90th_percentile": 262.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 327.59, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 327.59, "10th_percentile": 327.59, "90th_percentile": 327.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 172.64, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 172.64, "10th_percentile": 172.64, "90th_percentile": 172.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 155.28, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 155.28, "10th_percentile": 155.28, "90th_percentile": 155.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 278.45, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 278.45, "10th_percentile": 278.45, "90th_percentile": 278.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 163.8, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 163.8, "10th_percentile": 163.8, "90th_percentile": 163.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 245.69, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 245.69, "10th_percentile": 245.69, "90th_percentile": 245.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 212.93, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 212.93, "10th_percentile": 212.93, "90th_percentile": 212.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 203.11, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 203.11, "10th_percentile": 203.11, "90th_percentile": 203.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 203.11, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 203.11, "10th_percentile": 203.11, "90th_percentile": 203.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 327.59, "10th_percentile": 327.59, "90th_percentile": 327.59, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 327.59, "10th_percentile": 327.59, "90th_percentile": 327.59, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 327.59, "10th_percentile": 327.59, "90th_percentile": 327.59, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 327.59, "10th_percentile": 327.59, "90th_percentile": 327.59, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 327.59, "10th_percentile": 327.59, "90th_percentile": 327.59, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 327.59, "10th_percentile": 327.59, "90th_percentile": 327.59, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 327.59, "10th_percentile": 327.59, "90th_percentile": 327.59, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 327.59, "10th_percentile": 327.59, "90th_percentile": 327.59, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 327.59, "10th_percentile": 327.59, "90th_percentile": 327.59, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 327.59, "10th_percentile": 327.59, "90th_percentile": 327.59, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 327.59, "10th_percentile": 327.59, "90th_percentile": 327.59, "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": 429.64, "maximum": 2635.8, "setting": "outpatient", "gross_charge": 2635.8, "discounted_cash": 1845.06, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 738.02, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 738.02, "10th_percentile": 738.02, "90th_percentile": 738.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 949.94, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 949.94, "10th_percentile": 949.94, "90th_percentile": 949.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1473.41, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1473.41, "10th_percentile": 1473.41, "90th_percentile": 1473.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 745.4, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 745.4, "10th_percentile": 745.4, "90th_percentile": 745.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 1837.68, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1837.68, "10th_percentile": 1837.68, "90th_percentile": 1837.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 1634.2, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1634.2, "10th_percentile": 1634.2, "90th_percentile": 1634.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 2372.22, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 2372.22, "10th_percentile": 2372.22, "90th_percentile": 2372.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 1317.9, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 1317.9, "10th_percentile": 1317.9, "90th_percentile": 1317.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 1713.27, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 1713.27, "10th_percentile": 1713.27, "90th_percentile": 1713.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 1976.85, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 1976.85, "10th_percentile": 1976.85, "90th_percentile": 1976.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 2240.43, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 2240.43, "10th_percentile": 2240.43, "90th_percentile": 2240.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 1249.37, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1249.37, "10th_percentile": 1249.37, "90th_percentile": 1249.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2635.8, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2635.8, "10th_percentile": 2635.8, "90th_percentile": 2635.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 1389.07, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1389.07, "10th_percentile": 1389.07, "90th_percentile": 1389.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 1660.55, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 1660.55, "10th_percentile": 1660.55, "90th_percentile": 1660.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 574.6, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 574.6, "10th_percentile": 574.6, "90th_percentile": 574.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 1291.54, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1291.54, "10th_percentile": 1291.54, "90th_percentile": 1291.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 2108.64, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 2108.64, "10th_percentile": 2108.64, "90th_percentile": 2108.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 1317.9, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1317.9, "10th_percentile": 1317.9, "90th_percentile": 1317.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 2108.64, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 2108.64, "10th_percentile": 2108.64, "90th_percentile": 2108.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 1692.97, "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": 1692.97, "10th_percentile": 1692.97, "90th_percentile": 1692.97, "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": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 1976.85, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 1976.85, "10th_percentile": 1976.85, "90th_percentile": 1976.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 1818.7, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 1818.7, "10th_percentile": 1818.7, "90th_percentile": 1818.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2635.8, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2635.8, "10th_percentile": 2635.8, "90th_percentile": 2635.8, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 2635.8, "10th_percentile": 2635.8, "90th_percentile": 2635.8, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2635.8, "10th_percentile": 2635.8, "90th_percentile": 2635.8, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2635.8, "10th_percentile": 2635.8, "90th_percentile": 2635.8, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2635.8, "10th_percentile": 2635.8, "90th_percentile": 2635.8, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2635.8, "10th_percentile": 2635.8, "90th_percentile": 2635.8, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2635.8, "10th_percentile": 2635.8, "90th_percentile": 2635.8, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2635.8, "10th_percentile": 2635.8, "90th_percentile": 2635.8, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 760.16, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 760.16, "10th_percentile": 760.16, "90th_percentile": 760.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 2372.22, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 2372.22, "10th_percentile": 2372.22, "90th_percentile": 2372.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 1789.71, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1789.71, "10th_percentile": 1789.71, "90th_percentile": 1789.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 1837.68, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1837.68, "10th_percentile": 1837.68, "90th_percentile": 1837.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 429.64, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 429.64, "10th_percentile": 429.64, "90th_percentile": 429.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 949.94, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 949.94, "10th_percentile": 949.94, "90th_percentile": 949.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 1634.2, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1634.2, "10th_percentile": 1634.2, "90th_percentile": 1634.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2635.8, "10th_percentile": 2635.8, "90th_percentile": 2635.8, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2635.8, "10th_percentile": 2635.8, "90th_percentile": 2635.8, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2635.8, "10th_percentile": 2635.8, "90th_percentile": 2635.8, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2635.8, "10th_percentile": 2635.8, "90th_percentile": 2635.8, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "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": 0.67, "maximum": 4.5, "setting": "outpatient", "gross_charge": 4.5, "discounted_cash": 3.15, "payers_information": [ { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "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": "DCH BLUE CROSS 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": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "DCH 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": "DCH 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": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH 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": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "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": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $4.50 @ 12.5% = $0.56 due to $0.00 Claim Price", "median_amount": 0.56, "10th_percentile": 0.56, "90th_percentile": 0.56, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $4.50 @ 12.5% = $0.56 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $4.50 @ 6.8% = $0.31 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": 0.31, "10th_percentile": 0.31, "90th_percentile": 0.31, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $4.50 @ 6.8% = $0.31 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": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $4.50 @ 6.8% = $0.31 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": 0.31, "10th_percentile": 0.31, "90th_percentile": 0.31, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $4.50 @ 6.8% = $0.31 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $4.50 @ 6.8% = $0.31 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": 0.31, "10th_percentile": 0.31, "90th_percentile": 0.31, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $4.50 @ 6.8% = $0.31 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": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 2.79, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "Drugs/Agents Default; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.79, "10th_percentile": 2.79, "90th_percentile": 2.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 3.06, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "Drugs/Agents Default; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.06, "10th_percentile": 3.06, "90th_percentile": 3.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.73, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 0.73, "10th_percentile": 0.73, "90th_percentile": 0.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 3.14, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.14, "10th_percentile": 3.14, "90th_percentile": 3.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 1.05, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 4.05, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% 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 SERVICES; 90% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.67, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.67, "10th_percentile": 0.67, "90th_percentile": 0.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.81, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.81, "10th_percentile": 0.81, "90th_percentile": 0.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.67, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.67, "10th_percentile": 0.67, "90th_percentile": 0.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 3.14, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.14, "10th_percentile": 3.14, "90th_percentile": 3.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2.52, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.52, "10th_percentile": 2.52, "90th_percentile": 2.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 1.05, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 2.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH 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": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 3.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 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 DEF; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 2.79, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "Drugs/Agents Default; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.79, "10th_percentile": 2.79, "90th_percentile": 2.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 3.11, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 3.11, "10th_percentile": 3.11, "90th_percentile": 3.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 3.38, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 3.38, "10th_percentile": 3.38, "90th_percentile": 3.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 2.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 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 SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 2.93, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% 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 procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 3.83, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 3.83, "10th_percentile": 3.83, "90th_percentile": 3.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH 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": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 4.05, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% 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 SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 3.38, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 3.38, "10th_percentile": 3.38, "90th_percentile": 3.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH 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": "DCH UHC CORE", "standard_charge_dollar": 2.13, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.13, "10th_percentile": 2.13, "90th_percentile": 2.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 2.37, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.37, "10th_percentile": 2.37, "90th_percentile": 2.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH 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": "MULTIPLAN/PHCS [142]", "plan_name": "DCH 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" } ] } ] }, { "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": 0.67, "maximum": 4.5, "setting": "outpatient", "gross_charge": 4.5, "discounted_cash": 3.15, "payers_information": [ { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "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": "DCH BLUE CROSS 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": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "DCH 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": "DCH 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": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH 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": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "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": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $4.50 @ 12.5% = $0.56 due to $0.00 Claim Price", "median_amount": 0.56, "10th_percentile": 0.56, "90th_percentile": 0.56, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $4.50 @ 12.5% = $0.56 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $4.50 @ 6.8% = $0.31 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": 0.31, "10th_percentile": 0.31, "90th_percentile": 0.31, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $4.50 @ 6.8% = $0.31 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": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $4.50 @ 6.8% = $0.31 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": 0.31, "10th_percentile": 0.31, "90th_percentile": 0.31, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $4.50 @ 6.8% = $0.31 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $4.50 @ 6.8% = $0.31 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": 0.31, "10th_percentile": 0.31, "90th_percentile": 0.31, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $4.50 @ 6.8% = $0.31 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": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 2.79, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "Drugs/Agents Default; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.79, "10th_percentile": 2.79, "90th_percentile": 2.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 3.06, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "Drugs/Agents Default; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.06, "10th_percentile": 3.06, "90th_percentile": 3.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.73, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 0.73, "10th_percentile": 0.73, "90th_percentile": 0.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 3.14, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.14, "10th_percentile": 3.14, "90th_percentile": 3.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 1.05, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 4.05, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% 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 SERVICES; 90% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.67, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.67, "10th_percentile": 0.67, "90th_percentile": 0.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.81, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.81, "10th_percentile": 0.81, "90th_percentile": 0.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.67, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.67, "10th_percentile": 0.67, "90th_percentile": 0.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 3.14, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.14, "10th_percentile": 3.14, "90th_percentile": 3.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2.52, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.52, "10th_percentile": 2.52, "90th_percentile": 2.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 1.05, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 2.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH 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": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 3.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 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 DEF; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 2.79, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "Drugs/Agents Default; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.79, "10th_percentile": 2.79, "90th_percentile": 2.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 3.11, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 3.11, "10th_percentile": 3.11, "90th_percentile": 3.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 3.38, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 3.38, "10th_percentile": 3.38, "90th_percentile": 3.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 2.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 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 SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 2.93, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% 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 procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 3.83, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 3.83, "10th_percentile": 3.83, "90th_percentile": 3.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH 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": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 4.05, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% 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 SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 3.38, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 3.38, "10th_percentile": 3.38, "90th_percentile": 3.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH 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": "DCH UHC CORE", "standard_charge_dollar": 2.13, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.13, "10th_percentile": 2.13, "90th_percentile": 2.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 2.37, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.37, "10th_percentile": 2.37, "90th_percentile": 2.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH 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": "MULTIPLAN/PHCS [142]", "plan_name": "DCH 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" } ] } ] }, { "description": "ATHEROSCLEROSIS WITHOUT MCC", "code_information": [ { "code": "303", "type": "MS-DRG" } ], "standard_charges": [ { "minimum": 4790.38, "maximum": 10493.17, "setting": "inpatient", "gross_charge": 41870.5, "discounted_cash": 29309.35, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.802661392; Using historical claim(s); Scope: All Financial Classes; Cases: 6; All IP Services; 100% Billed", "median_amount": 41830.5, "10th_percentile": 41830.5, "90th_percentile": 41830.5, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.802661392; Using historical claim(s); Scope: All Financial Classes; Cases: 6; All IP Services - OON; 100% Billed", "median_amount": 41830.5, "10th_percentile": 41830.5, "90th_percentile": 41830.5, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.802661392; Using historical claim(s); Scope: All Financial Classes; Cases: 6; Inpatient (Non Covered - Verify Coverage); 100% Billed", "median_amount": 41830.5, "10th_percentile": 41830.5, "90th_percentile": 41830.5, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_percentage": 85.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 35555.93, "10th_percentile": 35555.93, "90th_percentile": 35555.93, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_percentage": 65.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 27189.83, "10th_percentile": 27189.83, "90th_percentile": 27189.83, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 31372.88, "10th_percentile": 31372.88, "90th_percentile": 31372.88, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 20915.25, "10th_percentile": 20915.25, "90th_percentile": 20915.25, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_percentage": 16.3, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 6818.38, "10th_percentile": 6818.38, "90th_percentile": 6818.38, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 33464.4, "10th_percentile": 33464.4, "90th_percentile": 33464.4, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_percentage": 90.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 37647.45, "10th_percentile": 37647.45, "90th_percentile": 37647.45, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_percentage": 90.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 37647.45, "10th_percentile": 37647.45, "90th_percentile": 37647.45, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_percentage": 49.0, "standard_charge_algorithm": "Re-evaluated: HLB.802661392; Using historical claim(s); Scope: All Financial Classes; Cases: 6; IP Services. ADP RATE (for patient estimates only); 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20496.95, "10th_percentile": 20496.95, "90th_percentile": 20496.95, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_percentage": 67.8, "standard_charge_algorithm": "Re-evaluated: HLB.802661392; Using historical claim(s); Scope: All Financial Classes; Cases: 6; All Inpatient Services; 67.8% Billed", "median_amount": 28361.08, "10th_percentile": 28361.08, "90th_percentile": 28361.08, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Re-evaluated: HLB.802661392; Using historical claim(s); Scope: All Financial Classes; Cases: 6; Inpatient Services; 63% Billed", "median_amount": 26353.22, "10th_percentile": 26353.22, "90th_percentile": 26353.22, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 10493.17, "standard_charge_algorithm": "Re-evaluated: HLB.802661392; Using historical claim(s); Scope: All Financial Classes; Cases: 6; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.6732, Rate: 15,587.00, and; Pricing Extension - NM HB XR PRC - DCH 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": 10493.17, "10th_percentile": 10493.17, "90th_percentile": 10493.17, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 5063.14, "standard_charge_algorithm": "Re-evaluated: HLB.802661392; Using historical claim(s); Scope: All Financial Classes; Cases: 6; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.6732, Rate: 7,521.00, and; Pricing Extension - NM HB XR PRC - DCH 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": 5063.14, "10th_percentile": 5063.14, "90th_percentile": 5063.14, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 6046.01, "standard_charge_algorithm": "Re-evaluated: HLB.802661392; Using historical claim(s); Scope: All Financial Classes; Cases: 6; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.6732, Rate: 8,981.00, and; Pricing Extension - NM HB XR PRC - DCH 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": 6046.01, "10th_percentile": 6046.01, "90th_percentile": 6046.01, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 4996.49, "standard_charge_algorithm": "Re-evaluated: HLB.802661392; Using historical claim(s); Scope: All Financial Classes; Cases: 6; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.6732, Rate: 7,422.00, and; Pricing Extension - NM HB XR PRC - DCH BCBS CHOICE SELECT CASE RATE W/OUTLIER S*", "median_amount": 4996.49, "10th_percentile": 4996.49, "90th_percentile": 4996.49, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 5096.8, "standard_charge_algorithm": "Re-evaluated: HLB.802661392; Using historical claim(s); Scope: All Financial Classes; Cases: 6; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.6732, Rate: 7,571.00, and; Pricing Extension - NM HB XR PRC - DCH 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": 5096.8, "10th_percentile": 5096.8, "90th_percentile": 5096.8, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 10493.17, "standard_charge_algorithm": "Re-evaluated: HLB.802661392; Using historical claim(s); Scope: All Financial Classes; Cases: 6; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.6732, Rate: 15,587.00, and; Pricing Extension - NM HB XR PRC - DCH 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": 10493.17, "10th_percentile": 10493.17, "90th_percentile": 10493.17, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 5063.14, "standard_charge_algorithm": "Re-evaluated: HLB.802661392; Using historical claim(s); Scope: All Financial Classes; Cases: 6; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.6732, Rate: 7,521.00, and; Pricing Extension - NM HB XR PRC - DCH 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": 5063.14, "10th_percentile": 5063.14, "90th_percentile": 5063.14, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_dollar": 4790.38, "standard_charge_algorithm": "Re-evaluated: HLB.802661392; Using historical claim(s); Scope: All Financial Classes; Cases: 6; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 0.67, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $5,614.35; Total: $5,614.35", "median_amount": 5614.35, "10th_percentile": 5614.35, "90th_percentile": 5614.35, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.802661392; Using historical claim(s); Scope: All Financial Classes; Cases: 6; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 0.67, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $5,614.35; Total: $5,614.35" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 4790.38, "standard_charge_algorithm": "Re-evaluated: HLB.802661392; Using historical claim(s); Scope: All Financial Classes; Cases: 6; 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: $5,203.40; Total: $5,203.40 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5203.4, "10th_percentile": 5203.4, "90th_percentile": 5203.4, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.802661392; Using historical claim(s); Scope: All Financial Classes; Cases: 6; 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: $5,203.40; Total: $5,203.40 Paid at contractual rate, which is the lesser of 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": "DCH HUMANA MEDICARE ADVT", "standard_charge_dollar": 4790.38, "standard_charge_algorithm": "Re-evaluated: HLB.802661392; Using historical claim(s); Scope: All Financial Classes; Cases: 6; 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: $5,171.17; Total: $5,171.17 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5171.17, "10th_percentile": 5171.17, "90th_percentile": 5171.17, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.802661392; Using historical claim(s); Scope: All Financial Classes; Cases: 6; 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: $5,171.17; Total: $5,171.17 Paid at contractual rate, which is the lesser 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": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_dollar": 4790.38, "standard_charge_algorithm": "Re-evaluated: HLB.802661392; Using historical claim(s); Scope: All Financial Classes; Cases: 6; 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: $5,203.40; Percentage applied: 97.00%; Total: $5,047.30 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5047.3, "10th_percentile": 5047.3, "90th_percentile": 5047.3, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.802661392; Using historical claim(s); Scope: All Financial Classes; Cases: 6; 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: $5,203.40; Percentage applied: 97.00%; Total: $5,047.30 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "ATROPINE 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": 31.25, "maximum": 209.75, "setting": "outpatient", "gross_charge": 209.75, "discounted_cash": 146.82, "payers_information": [ { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 209.75, "10th_percentile": 209.75, "90th_percentile": 209.75, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 209.75, "10th_percentile": 209.75, "90th_percentile": 209.75, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 209.75, "10th_percentile": 209.75, "90th_percentile": 209.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 209.75, "10th_percentile": 209.75, "90th_percentile": 209.75, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 209.75, "10th_percentile": 209.75, "90th_percentile": 209.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 209.75, "10th_percentile": 209.75, "90th_percentile": 209.75, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 209.75, "10th_percentile": 209.75, "90th_percentile": 209.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $209.75 @ 12.5% = $26.22 due to $0.00 Claim Price", "median_amount": 26.22, "10th_percentile": 26.22, "90th_percentile": 26.22, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $209.75 @ 12.5% = $26.22 due to $0.00 Claim Price" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $209.75 @ 6.8% = $14.26 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": 14.26, "10th_percentile": 14.26, "90th_percentile": 14.26, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $209.75 @ 6.8% = $14.26 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $209.75 @ 6.8% = $14.26 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": 14.26, "10th_percentile": 14.26, "90th_percentile": 14.26, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $209.75 @ 6.8% = $14.26 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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $209.75 @ 6.8% = $14.26 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": 14.26, "10th_percentile": 14.26, "90th_percentile": 14.26, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $209.75 @ 6.8% = $14.26 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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 48.87, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 48.87, "10th_percentile": 48.87, "90th_percentile": 48.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 37.76, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 37.76, "10th_percentile": 37.76, "90th_percentile": 37.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 117.25, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 117.25, "10th_percentile": 117.25, "90th_percentile": 117.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 146.24, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 146.24, "10th_percentile": 146.24, "90th_percentile": 146.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 31.25, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 31.25, "10th_percentile": 31.25, "90th_percentile": 31.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 31.25, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 31.25, "10th_percentile": 31.25, "90th_percentile": 31.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 188.78, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 188.78, "10th_percentile": 188.78, "90th_percentile": 188.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 188.78, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 188.78, "10th_percentile": 188.78, "90th_percentile": 188.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 136.34, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 136.34, "10th_percentile": 136.34, "90th_percentile": 136.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 157.31, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 157.31, "10th_percentile": 157.31, "90th_percentile": 157.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 104.88, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 104.88, "10th_percentile": 104.88, "90th_percentile": 104.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 178.29, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 178.29, "10th_percentile": 178.29, "90th_percentile": 178.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 146.24, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 146.24, "10th_percentile": 146.24, "90th_percentile": 146.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 144.73, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 144.73, "10th_percentile": 144.73, "90th_percentile": 144.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 167.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 167.8, "10th_percentile": 167.8, "90th_percentile": 167.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 104.88, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 104.88, "10th_percentile": 104.88, "90th_percentile": 104.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 157.31, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 157.31, "10th_percentile": 157.31, "90th_percentile": 157.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 132.14, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 132.14, "10th_percentile": 132.14, "90th_percentile": 132.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 167.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 167.8, "10th_percentile": 167.8, "90th_percentile": 167.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 34.19, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 34.19, "10th_percentile": 34.19, "90th_percentile": 34.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 209.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 209.75, "10th_percentile": 209.75, "90th_percentile": 209.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 48.87, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 48.87, "10th_percentile": 48.87, "90th_percentile": 48.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 209.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 209.75, "10th_percentile": 209.75, "90th_percentile": 209.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% 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": 54.65, "maximum": 335.25, "setting": "outpatient", "gross_charge": 335.25, "discounted_cash": 234.67, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 176.68, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 176.68, "10th_percentile": 176.68, "90th_percentile": 176.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 335.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 335.25, "10th_percentile": 335.25, "90th_percentile": 335.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 158.91, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 158.91, "10th_percentile": 158.91, "90th_percentile": 158.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 215.33, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 215.33, "10th_percentile": 215.33, "90th_percentile": 215.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 335.25, "10th_percentile": 335.25, "90th_percentile": 335.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 335.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 335.25, "10th_percentile": 335.25, "90th_percentile": 335.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 211.21, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 211.21, "10th_percentile": 211.21, "90th_percentile": 211.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 268.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 268.2, "10th_percentile": 268.2, "90th_percentile": 268.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 231.32, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 231.32, "10th_percentile": 231.32, "90th_percentile": 231.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 167.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 167.63, "10th_percentile": 167.63, "90th_percentile": 167.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 251.44, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 251.44, "10th_percentile": 251.44, "90th_percentile": 251.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 268.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 268.2, "10th_percentile": 268.2, "90th_percentile": 268.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 73.08, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 73.08, "10th_percentile": 73.08, "90th_percentile": 73.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 164.27, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 164.27, "10th_percentile": 164.27, "90th_percentile": 164.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 227.63, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 227.63, "10th_percentile": 227.63, "90th_percentile": 227.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 54.65, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 54.65, "10th_percentile": 54.65, "90th_percentile": 54.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 233.74, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 233.74, "10th_percentile": 233.74, "90th_percentile": 233.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 120.82, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 120.82, "10th_percentile": 120.82, "90th_percentile": 120.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH HFN PLAT", "standard_charge_dollar": 217.91, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 217.91, "10th_percentile": 217.91, "90th_percentile": 217.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 284.96, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 284.96, "10th_percentile": 284.96, "90th_percentile": 284.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 167.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 167.63, "10th_percentile": 167.63, "90th_percentile": 167.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 251.44, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 251.44, "10th_percentile": 251.44, "90th_percentile": 251.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 187.4, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 187.4, "10th_percentile": 187.4, "90th_percentile": 187.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 233.74, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 233.74, "10th_percentile": 233.74, "90th_percentile": 233.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 93.87, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 93.87, "10th_percentile": 93.87, "90th_percentile": 93.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 94.81, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 94.81, "10th_percentile": 94.81, "90th_percentile": 94.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 120.82, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 120.82, "10th_percentile": 120.82, "90th_percentile": 120.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 96.69, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 96.69, "10th_percentile": 96.69, "90th_percentile": 96.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 207.86, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 207.86, "10th_percentile": 207.86, "90th_percentile": 207.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 207.86, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 207.86, "10th_percentile": 207.86, "90th_percentile": 207.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 301.73, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 301.73, "10th_percentile": 301.73, "90th_percentile": 301.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 301.73, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 301.73, "10th_percentile": 301.73, "90th_percentile": 301.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 335.25, "10th_percentile": 335.25, "90th_percentile": 335.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 335.25, "10th_percentile": 335.25, "90th_percentile": 335.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 335.25, "10th_percentile": 335.25, "90th_percentile": 335.25, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 335.25, "10th_percentile": 335.25, "90th_percentile": 335.25, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 335.25, "10th_percentile": 335.25, "90th_percentile": 335.25, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 335.25, "10th_percentile": 335.25, "90th_percentile": 335.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 335.25, "10th_percentile": 335.25, "90th_percentile": 335.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 335.25, "10th_percentile": 335.25, "90th_percentile": 335.25, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 335.25, "10th_percentile": 335.25, "90th_percentile": 335.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 335.25, "10th_percentile": 335.25, "90th_percentile": 335.25, "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": 73.43, "maximum": 450.5, "setting": "outpatient", "gross_charge": 450.5, "discounted_cash": 315.35, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 162.36, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 162.36, "10th_percentile": 162.36, "90th_percentile": 162.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 162.36, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 162.36, "10th_percentile": 162.36, "90th_percentile": 162.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 314.09, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 314.09, "10th_percentile": 314.09, "90th_percentile": 314.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 314.09, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 314.09, "10th_percentile": 314.09, "90th_percentile": 314.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 405.45, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 405.45, "10th_percentile": 405.45, "90th_percentile": 405.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 405.45, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 405.45, "10th_percentile": 405.45, "90th_percentile": 405.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 279.31, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 279.31, "10th_percentile": 279.31, "90th_percentile": 279.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 279.31, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 279.31, "10th_percentile": 279.31, "90th_percentile": 279.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH HFN PPO", "standard_charge_dollar": 382.93, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 382.93, "10th_percentile": 382.93, "90th_percentile": 382.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 292.83, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 292.83, "10th_percentile": 292.83, "90th_percentile": 292.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 225.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 225.25, "10th_percentile": 225.25, "90th_percentile": 225.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 337.88, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 337.88, "10th_percentile": 337.88, "90th_percentile": 337.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 126.14, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 126.14, "10th_percentile": 126.14, "90th_percentile": 126.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 251.83, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 251.83, "10th_percentile": 251.83, "90th_percentile": 251.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 127.4, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 127.4, "10th_percentile": 127.4, "90th_percentile": 127.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 129.92, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 129.92, "10th_percentile": 129.92, "90th_percentile": 129.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 450.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 450.5, "10th_percentile": 450.5, "90th_percentile": 450.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 237.41, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 237.41, "10th_percentile": 237.41, "90th_percentile": 237.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 213.54, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 213.54, "10th_percentile": 213.54, "90th_percentile": 213.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 283.82, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 283.82, "10th_percentile": 283.82, "90th_percentile": 283.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 220.75, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 220.75, "10th_percentile": 220.75, "90th_percentile": 220.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 360.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 360.4, "10th_percentile": 360.4, "90th_percentile": 360.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 98.21, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 98.21, "10th_percentile": 98.21, "90th_percentile": 98.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 225.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 225.25, "10th_percentile": 225.25, "90th_percentile": 225.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 360.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 360.4, "10th_percentile": 360.4, "90th_percentile": 360.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 337.88, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 337.88, "10th_percentile": 337.88, "90th_percentile": 337.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 289.36, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 289.36, "10th_percentile": 289.36, "90th_percentile": 289.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 450.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 450.5, "10th_percentile": 450.5, "90th_percentile": 450.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 310.85, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 310.85, "10th_percentile": 310.85, "90th_percentile": 310.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 73.43, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 73.43, "10th_percentile": 73.43, "90th_percentile": 73.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 305.89, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 305.89, "10th_percentile": 305.89, "90th_percentile": 305.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 450.5, "10th_percentile": 450.5, "90th_percentile": 450.5, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 450.5, "10th_percentile": 450.5, "90th_percentile": 450.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 450.5, "10th_percentile": 450.5, "90th_percentile": 450.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 450.5, "10th_percentile": 450.5, "90th_percentile": 450.5, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 450.5, "10th_percentile": 450.5, "90th_percentile": 450.5, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 450.5, "10th_percentile": 450.5, "90th_percentile": 450.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 450.5, "10th_percentile": 450.5, "90th_percentile": 450.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 450.5, "10th_percentile": 450.5, "90th_percentile": 450.5, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 450.5, "10th_percentile": 450.5, "90th_percentile": 450.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 450.5, "10th_percentile": 450.5, "90th_percentile": 450.5, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 450.5, "10th_percentile": 450.5, "90th_percentile": 450.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "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": 764.0, "maximum": 4687.12, "setting": "outpatient", "gross_charge": 4687.12, "discounted_cash": 3280.98, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 2906.01, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2906.01, "10th_percentile": 2906.01, "90th_percentile": 2906.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 2906.01, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2906.01, "10th_percentile": 2906.01, "90th_percentile": 2906.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1351.77, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1351.77, "10th_percentile": 1351.77, "90th_percentile": 1351.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 3267.86, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3267.86, "10th_percentile": 3267.86, "90th_percentile": 3267.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1325.52, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1325.52, "10th_percentile": 1325.52, "90th_percentile": 1325.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2620.1, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2620.1, "10th_percentile": 2620.1, "90th_percentile": 2620.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 1689.24, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1689.24, "10th_percentile": 1689.24, "90th_percentile": 1689.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1312.39, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1312.39, "10th_percentile": 1312.39, "90th_percentile": 1312.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 4218.41, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 4218.41, "10th_percentile": 4218.41, "90th_percentile": 4218.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 4218.41, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 4218.41, "10th_percentile": 4218.41, "90th_percentile": 4218.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 2343.56, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 2343.56, "10th_percentile": 2343.56, "90th_percentile": 2343.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 3046.63, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 3046.63, "10th_percentile": 3046.63, "90th_percentile": 3046.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 3515.34, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 3515.34, "10th_percentile": 3515.34, "90th_percentile": 3515.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 3984.05, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 3984.05, "10th_percentile": 3984.05, "90th_percentile": 3984.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 3182.55, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3182.55, "10th_percentile": 3182.55, "90th_percentile": 3182.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4687.12, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4687.12, "10th_percentile": 4687.12, "90th_percentile": 4687.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 3749.7, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 3749.7, "10th_percentile": 3749.7, "90th_percentile": 3749.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 2221.69, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2221.69, "10th_percentile": 2221.69, "90th_percentile": 2221.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 2470.11, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2470.11, "10th_percentile": 2470.11, "90th_percentile": 2470.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 4687.12, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 4687.12, "10th_percentile": 4687.12, "90th_percentile": 4687.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 3010.54, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 3010.54, "10th_percentile": 3010.54, "90th_percentile": 3010.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 3515.34, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 3515.34, "10th_percentile": 3515.34, "90th_percentile": 3515.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 1021.79, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1021.79, "10th_percentile": 1021.79, "90th_percentile": 1021.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 3749.7, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 3749.7, "10th_percentile": 3749.7, "90th_percentile": 3749.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 2296.69, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2296.69, "10th_percentile": 2296.69, "90th_percentile": 2296.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 2343.56, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2343.56, "10th_percentile": 2343.56, "90th_percentile": 2343.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 3267.86, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3267.86, "10th_percentile": 3267.86, "90th_percentile": 3267.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 3234.11, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 3234.11, "10th_percentile": 3234.11, "90th_percentile": 3234.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 764.0, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 764.0, "10th_percentile": 764.0, "90th_percentile": 764.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 1689.24, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1689.24, "10th_percentile": 1689.24, "90th_percentile": 1689.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 2952.89, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 2952.89, "10th_percentile": 2952.89, "90th_percentile": 2952.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 4687.12, "10th_percentile": 4687.12, "90th_percentile": 4687.12, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4687.12, "10th_percentile": 4687.12, "90th_percentile": 4687.12, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4687.12, "10th_percentile": 4687.12, "90th_percentile": 4687.12, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4687.12, "10th_percentile": 4687.12, "90th_percentile": 4687.12, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4687.12, "10th_percentile": 4687.12, "90th_percentile": 4687.12, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4687.12, "10th_percentile": 4687.12, "90th_percentile": 4687.12, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4687.12, "10th_percentile": 4687.12, "90th_percentile": 4687.12, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4687.12, "10th_percentile": 4687.12, "90th_percentile": 4687.12, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4687.12, "10th_percentile": 4687.12, "90th_percentile": 4687.12, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4687.12, "10th_percentile": 4687.12, "90th_percentile": 4687.12, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4687.12, "10th_percentile": 4687.12, "90th_percentile": 4687.12, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "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": 1.89, "maximum": 11.6, "setting": "outpatient", "gross_charge": 11.6, "discounted_cash": 8.12, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 7.88, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.88, "10th_percentile": 7.88, "90th_percentile": 7.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 1.89, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 1.89, "10th_percentile": 1.89, "90th_percentile": 1.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 7.45, "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": 7.45, "10th_percentile": 7.45, "90th_percentile": 7.45, "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": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 8.7, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 8.7, "10th_percentile": 8.7, "90th_percentile": 8.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 5.8, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.8, "10th_percentile": 5.8, "90th_percentile": 5.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 5.5, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.5, "10th_percentile": 5.5, "90th_percentile": 5.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 6.11, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.11, "10th_percentile": 6.11, "90th_percentile": 6.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 11.6, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 11.6, "10th_percentile": 11.6, "90th_percentile": 11.6, "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": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 2.53, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.53, "10th_percentile": 2.53, "90th_percentile": 2.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH COMPSYCH", "standard_charge_dollar": 9.28, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 9.28, "10th_percentile": 9.28, "90th_percentile": 9.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 7.31, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 7.31, "10th_percentile": 7.31, "90th_percentile": 7.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 11.6, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 11.6, "10th_percentile": 11.6, "90th_percentile": 11.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 8.0, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 8.0, "10th_percentile": 8.0, "90th_percentile": 8.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 3.28, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.28, "10th_percentile": 3.28, "90th_percentile": 3.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 3.35, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.35, "10th_percentile": 3.35, "90th_percentile": 3.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 6.48, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.48, "10th_percentile": 6.48, "90th_percentile": 6.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 3.25, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.25, "10th_percentile": 3.25, "90th_percentile": 3.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 5.68, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.68, "10th_percentile": 5.68, "90th_percentile": 5.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 9.28, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 9.28, "10th_percentile": 9.28, "90th_percentile": 9.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 9.86, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 9.86, "10th_percentile": 9.86, "90th_percentile": 9.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 7.54, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 7.54, "10th_percentile": 7.54, "90th_percentile": 7.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 5.8, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 5.8, "10th_percentile": 5.8, "90th_percentile": 5.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 8.7, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 8.7, "10th_percentile": 8.7, "90th_percentile": 8.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 10.44, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% 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; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 10.44, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% 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; 90% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 7.19, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.19, "10th_percentile": 7.19, "90th_percentile": 7.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 7.19, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.19, "10th_percentile": 7.19, "90th_percentile": 7.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 4.18, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.18, "10th_percentile": 4.18, "90th_percentile": 4.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 4.18, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.18, "10th_percentile": 4.18, "90th_percentile": 4.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 8.09, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 8.09, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 11.6, "10th_percentile": 11.6, "90th_percentile": 11.6, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11.6, "10th_percentile": 11.6, "90th_percentile": 11.6, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11.6, "10th_percentile": 11.6, "90th_percentile": 11.6, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11.6, "10th_percentile": 11.6, "90th_percentile": 11.6, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11.6, "10th_percentile": 11.6, "90th_percentile": 11.6, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11.6, "10th_percentile": 11.6, "90th_percentile": 11.6, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11.6, "10th_percentile": 11.6, "90th_percentile": 11.6, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11.6, "10th_percentile": 11.6, "90th_percentile": 11.6, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11.6, "10th_percentile": 11.6, "90th_percentile": 11.6, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11.6, "10th_percentile": 11.6, "90th_percentile": 11.6, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11.6, "10th_percentile": 11.6, "90th_percentile": 11.6, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "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": 124.53, "maximum": 835.76, "setting": "outpatient", "gross_charge": 835.76, "discounted_cash": 585.03, "payers_information": [ { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 409.52, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 36.66, "10th_percentile": 36.66, "90th_percentile": 36.66, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 440.45, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.36, "10th_percentile": 16.36, "90th_percentile": 16.36, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 576.67, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 576.67, "10th_percentile": 576.67, "90th_percentile": 576.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 526.53, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 526.53, "10th_percentile": 526.53, "90th_percentile": 526.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 710.4, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 710.4, "10th_percentile": 710.4, "90th_percentile": 710.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 543.24, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 543.24, "10th_percentile": 543.24, "90th_percentile": 543.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 182.2, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.2, "10th_percentile": 20.2, "90th_percentile": 20.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH THE ALLIANCE", "standard_charge_dollar": 536.81, "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": 536.81, "10th_percentile": 536.81, "90th_percentile": 536.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 396.15, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 396.15, "10th_percentile": 396.15, "90th_percentile": 396.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 150.44, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 150.44, "10th_percentile": 150.44, "90th_percentile": 150.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 467.19, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 467.19, "10th_percentile": 467.19, "90th_percentile": 467.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 518.17, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 518.17, "10th_percentile": 518.17, "90th_percentile": 518.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH COMPSYCH", "standard_charge_dollar": 668.61, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 668.61, "10th_percentile": 668.61, "90th_percentile": 668.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 668.61, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 668.61, "10th_percentile": 668.61, "90th_percentile": 668.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 626.82, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 626.82, "10th_percentile": 626.82, "90th_percentile": 626.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 626.82, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% 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; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 752.18, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 752.18, "10th_percentile": 752.18, "90th_percentile": 752.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 124.53, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 124.53, "10th_percentile": 124.53, "90th_percentile": 124.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 417.88, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 417.88, "10th_percentile": 417.88, "90th_percentile": 417.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 417.88, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 417.88, "10th_percentile": 417.88, "90th_percentile": 417.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 582.69, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 582.69, "10th_percentile": 582.69, "90th_percentile": 582.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 835.76, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 835.76, "10th_percentile": 835.76, "90th_percentile": 835.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 835.76, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 835.76, "10th_percentile": 835.76, "90th_percentile": 835.76, "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": "DCH BCBS PPO", "standard_charge_dollar": 194.73, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 194.73, "10th_percentile": 194.73, "90th_percentile": 194.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $835.76 @ 6.8% = $56.83 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": 56.83, "10th_percentile": 56.83, "90th_percentile": 56.83, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $835.76 @ 6.8% = $56.83 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $835.76 @ 6.8% = $56.83 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": 56.83, "10th_percentile": 56.83, "90th_percentile": 56.83, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $835.76 @ 6.8% = $56.83 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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $835.76 @ 6.8% = $56.83 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": 56.83, "10th_percentile": 56.83, "90th_percentile": 56.83, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $835.76 @ 6.8% = $56.83 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": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $835.76 @ 12.5% = $104.47 due to $0.00 Claim Price", "median_amount": 104.47, "10th_percentile": 104.47, "90th_percentile": 104.47, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $835.76 @ 12.5% = $104.47 due to $0.00 Claim Price" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 835.76, "10th_percentile": 835.76, "90th_percentile": 835.76, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 835.76, "10th_percentile": 835.76, "90th_percentile": 835.76, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 835.76, "10th_percentile": 835.76, "90th_percentile": 835.76, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 752.18, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 752.18, "10th_percentile": 752.18, "90th_percentile": 752.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 582.69, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 582.69, "10th_percentile": 582.69, "90th_percentile": 582.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 124.53, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 124.53, "10th_percentile": 124.53, "90th_percentile": 124.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 194.73, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 194.73, "10th_percentile": 194.73, "90th_percentile": 194.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 518.17, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 518.17, "10th_percentile": 518.17, "90th_percentile": 518.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 567.48, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 567.48, "10th_percentile": 567.48, "90th_percentile": 567.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 136.23, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 136.23, "10th_percentile": 136.23, "90th_percentile": 136.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 835.76, "10th_percentile": 835.76, "90th_percentile": 835.76, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 835.76, "10th_percentile": 835.76, "90th_percentile": 835.76, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 835.76, "10th_percentile": 835.76, "90th_percentile": 835.76, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 835.76, "10th_percentile": 835.76, "90th_percentile": 835.76, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "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": 124.53, "maximum": 835.76, "setting": "outpatient", "gross_charge": 835.76, "discounted_cash": 585.03, "payers_information": [ { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 409.52, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 36.66, "10th_percentile": 36.66, "90th_percentile": 36.66, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 440.45, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.36, "10th_percentile": 16.36, "90th_percentile": 16.36, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 576.67, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 576.67, "10th_percentile": 576.67, "90th_percentile": 576.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 526.53, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 526.53, "10th_percentile": 526.53, "90th_percentile": 526.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 710.4, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 710.4, "10th_percentile": 710.4, "90th_percentile": 710.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 543.24, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 543.24, "10th_percentile": 543.24, "90th_percentile": 543.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 182.2, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.2, "10th_percentile": 20.2, "90th_percentile": 20.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH THE ALLIANCE", "standard_charge_dollar": 536.81, "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": 536.81, "10th_percentile": 536.81, "90th_percentile": 536.81, "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": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 567.48, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 567.48, "10th_percentile": 567.48, "90th_percentile": 567.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 396.15, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 396.15, "10th_percentile": 396.15, "90th_percentile": 396.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 136.23, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 136.23, "10th_percentile": 136.23, "90th_percentile": 136.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 150.44, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 150.44, "10th_percentile": 150.44, "90th_percentile": 150.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 467.19, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 467.19, "10th_percentile": 467.19, "90th_percentile": 467.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 518.17, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 518.17, "10th_percentile": 518.17, "90th_percentile": 518.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 518.17, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 518.17, "10th_percentile": 518.17, "90th_percentile": 518.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH COMPSYCH", "standard_charge_dollar": 668.61, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 668.61, "10th_percentile": 668.61, "90th_percentile": 668.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 668.61, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 668.61, "10th_percentile": 668.61, "90th_percentile": 668.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 626.82, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 626.82, "10th_percentile": 626.82, "90th_percentile": 626.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 626.82, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% 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; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 752.18, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 752.18, "10th_percentile": 752.18, "90th_percentile": 752.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 752.18, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 752.18, "10th_percentile": 752.18, "90th_percentile": 752.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 124.53, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 124.53, "10th_percentile": 124.53, "90th_percentile": 124.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 124.53, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 124.53, "10th_percentile": 124.53, "90th_percentile": 124.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 417.88, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 417.88, "10th_percentile": 417.88, "90th_percentile": 417.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 417.88, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 417.88, "10th_percentile": 417.88, "90th_percentile": 417.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 582.69, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 582.69, "10th_percentile": 582.69, "90th_percentile": 582.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 582.69, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 582.69, "10th_percentile": 582.69, "90th_percentile": 582.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 835.76, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 835.76, "10th_percentile": 835.76, "90th_percentile": 835.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 835.76, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 835.76, "10th_percentile": 835.76, "90th_percentile": 835.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 194.73, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 194.73, "10th_percentile": 194.73, "90th_percentile": 194.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 194.73, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 194.73, "10th_percentile": 194.73, "90th_percentile": 194.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $835.76 @ 6.8% = $56.83 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": 56.83, "10th_percentile": 56.83, "90th_percentile": 56.83, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $835.76 @ 6.8% = $56.83 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $835.76 @ 6.8% = $56.83 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": 56.83, "10th_percentile": 56.83, "90th_percentile": 56.83, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $835.76 @ 6.8% = $56.83 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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $835.76 @ 6.8% = $56.83 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": 56.83, "10th_percentile": 56.83, "90th_percentile": 56.83, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $835.76 @ 6.8% = $56.83 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": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $835.76 @ 12.5% = $104.47 due to $0.00 Claim Price", "median_amount": 104.47, "10th_percentile": 104.47, "90th_percentile": 104.47, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $835.76 @ 12.5% = $104.47 due to $0.00 Claim Price" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 835.76, "10th_percentile": 835.76, "90th_percentile": 835.76, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 835.76, "10th_percentile": 835.76, "90th_percentile": 835.76, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 835.76, "10th_percentile": 835.76, "90th_percentile": 835.76, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 835.76, "10th_percentile": 835.76, "90th_percentile": 835.76, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 835.76, "10th_percentile": 835.76, "90th_percentile": 835.76, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 835.76, "10th_percentile": 835.76, "90th_percentile": 835.76, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 835.76, "10th_percentile": 835.76, "90th_percentile": 835.76, "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": 124.53, "maximum": 835.76, "setting": "outpatient", "gross_charge": 835.76, "discounted_cash": 585.03, "payers_information": [ { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 409.52, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 36.66, "10th_percentile": 36.66, "90th_percentile": 36.66, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 440.45, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.36, "10th_percentile": 16.36, "90th_percentile": 16.36, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 150.44, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 150.44, "10th_percentile": 150.44, "90th_percentile": 150.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 467.19, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 467.19, "10th_percentile": 467.19, "90th_percentile": 467.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH THE ALLIANCE", "standard_charge_dollar": 536.81, "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": 536.81, "10th_percentile": 536.81, "90th_percentile": 536.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 396.15, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 396.15, "10th_percentile": 396.15, "90th_percentile": 396.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 526.53, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 526.53, "10th_percentile": 526.53, "90th_percentile": 526.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 567.48, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 567.48, "10th_percentile": 567.48, "90th_percentile": 567.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 136.23, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 136.23, "10th_percentile": 136.23, "90th_percentile": 136.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 710.4, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 710.4, "10th_percentile": 710.4, "90th_percentile": 710.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 543.24, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 543.24, "10th_percentile": 543.24, "90th_percentile": 543.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 182.2, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.2, "10th_percentile": 20.2, "90th_percentile": 20.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 576.67, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 576.67, "10th_percentile": 576.67, "90th_percentile": 576.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 752.18, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 752.18, "10th_percentile": 752.18, "90th_percentile": 752.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 752.18, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 752.18, "10th_percentile": 752.18, "90th_percentile": 752.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 124.53, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 124.53, "10th_percentile": 124.53, "90th_percentile": 124.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 124.53, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 124.53, "10th_percentile": 124.53, "90th_percentile": 124.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 582.69, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 582.69, "10th_percentile": 582.69, "90th_percentile": 582.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 582.69, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 582.69, "10th_percentile": 582.69, "90th_percentile": 582.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 194.73, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 194.73, "10th_percentile": 194.73, "90th_percentile": 194.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 194.73, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 194.73, "10th_percentile": 194.73, "90th_percentile": 194.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 626.82, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% 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; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 626.82, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 626.82, "10th_percentile": 626.82, "90th_percentile": 626.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 518.17, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 518.17, "10th_percentile": 518.17, "90th_percentile": 518.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 518.17, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 518.17, "10th_percentile": 518.17, "90th_percentile": 518.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 417.88, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 417.88, "10th_percentile": 417.88, "90th_percentile": 417.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 417.88, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 417.88, "10th_percentile": 417.88, "90th_percentile": 417.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 835.76, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 835.76, "10th_percentile": 835.76, "90th_percentile": 835.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 835.76, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 835.76, "10th_percentile": 835.76, "90th_percentile": 835.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 668.61, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 668.61, "10th_percentile": 668.61, "90th_percentile": 668.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 668.61, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 668.61, "10th_percentile": 668.61, "90th_percentile": 668.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $835.76 @ 12.5% = $104.47 due to $0.00 Claim Price", "median_amount": 104.47, "10th_percentile": 104.47, "90th_percentile": 104.47, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $835.76 @ 12.5% = $104.47 due to $0.00 Claim Price" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $835.76 @ 6.8% = $56.83 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": 56.83, "10th_percentile": 56.83, "90th_percentile": 56.83, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $835.76 @ 6.8% = $56.83 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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $835.76 @ 6.8% = $56.83 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": 56.83, "10th_percentile": 56.83, "90th_percentile": 56.83, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $835.76 @ 6.8% = $56.83 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $835.76 @ 6.8% = $56.83 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": 56.83, "10th_percentile": 56.83, "90th_percentile": 56.83, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $835.76 @ 6.8% = $56.83 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": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 835.76, "10th_percentile": 835.76, "90th_percentile": 835.76, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 835.76, "10th_percentile": 835.76, "90th_percentile": 835.76, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 835.76, "10th_percentile": 835.76, "90th_percentile": 835.76, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 835.76, "10th_percentile": 835.76, "90th_percentile": 835.76, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 835.76, "10th_percentile": 835.76, "90th_percentile": 835.76, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 835.76, "10th_percentile": 835.76, "90th_percentile": 835.76, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 835.76, "10th_percentile": 835.76, "90th_percentile": 835.76, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "Arthroscopy Hip Surgical W/Synovectomy", "code_information": [ { "code": "CASE-29863", "type": "LOCAL" }, { "code": "29863", "type": "CPT" }, { "code": "0360", "type": "RC" } ], "standard_charges": [ { "minimum": 1054.5, "maximum": 3919.5, "setting": "outpatient", "gross_charge": 113667.2, "discounted_cash": 79567.04, "payers_information": [ { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_percentage": 93.0, "standard_charge_algorithm": "Re-evaluated: HLB.840469974; Using new claim; Scope: All Financial Classes; Cases: 2; APCs; 93% Billed, and; Pricing Extension - NM HB XR PRC - 3M $0 RETURN & HAS APC FOR DCH & LESSOR OF; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 93% = $0.00. Percent of Claim Billed: $113,667.20 @ 12.5% = $14,208.40 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": 14208.4, "10th_percentile": 14208.4, "90th_percentile": 14208.4, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.840469974; Using new claim; Scope: All Financial Classes; Cases: 2; APCs; 93% Billed, and; Pricing Extension - NM HB XR PRC - 3M $0 RETURN & HAS APC FOR DCH & LESSOR OF; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 93% = $0.00. Percent of Claim Billed: $113,667.20 @ 12.5% = $14,208.40 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": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_percentage": 120.0, "standard_charge_algorithm": "Re-evaluated: HLB.840469974; Using new claim; Scope: All Financial Classes; Cases: 2; APCs; 120% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 120% = $0.00. Percent of Claim Billed: $113,667.20 @ 12.5% = $14,208.40 due to $0.00 Claim Price", "median_amount": 14208.4, "10th_percentile": 14208.4, "90th_percentile": 14208.4, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.840469974; Using new claim; Scope: All Financial Classes; Cases: 2; APCs; 120% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 120% = $0.00. Percent of Claim Billed: $113,667.20 @ 12.5% = $14,208.40 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_percentage": 120.0, "standard_charge_algorithm": "Re-evaluated: HLB.840469974; Using new claim; Scope: All Financial Classes; Cases: 2; APCs; 120% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 120% = $0.00. Percent of Claim Billed: $113,667.20 @ 12.5% = $14,208.40 due to $0.00 Claim Price", "median_amount": 14208.4, "10th_percentile": 14208.4, "90th_percentile": 14208.4, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.840469974; Using new claim; Scope: All Financial Classes; Cases: 2; APCs; 120% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 120% = $0.00. Percent of Claim Billed: $113,667.20 @ 12.5% = $14,208.40 due to $0.00 Claim Price" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.840469974; Using new claim; Scope: All Financial Classes; Cases: 2; APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $113,667.20 @ 12.5% = $14,208.40 due to $0.00 Claim Price", "median_amount": 14208.4, "10th_percentile": 14208.4, "90th_percentile": 14208.4, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.840469974; Using new claim; Scope: All Financial Classes; Cases: 2; APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $113,667.20 @ 12.5% = $14,208.40 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "DCH HUMANA MEDICARE ADVT", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.840469974; Using new claim; Scope: All Financial Classes; Cases: 2; APCs; 100% Billed, and; Pricing Extension - NM HB XR PRC - 3M $0 RETURN & HAS APC FOR DCH & LESSOR OF; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $113,667.20 @ 12.5% = $14,208.40 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": 14208.4, "10th_percentile": 14208.4, "90th_percentile": 14208.4, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.840469974; Using new claim; Scope: All Financial Classes; Cases: 2; APCs; 100% Billed, and; Pricing Extension - NM HB XR PRC - 3M $0 RETURN & HAS APC FOR DCH & LESSOR OF; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $113,667.20 @ 12.5% = $14,208.40 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 BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.840469974; Using new claim; Scope: All Financial Classes; Cases: 2; APCs; 100% Billed, and; Pricing Extension - NM HB XR PRC - 3M $0 RETURN & HAS APC FOR DCH & LESSOR OF; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $113,667.20 @ 12.5% = $14,208.40 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": 14208.4, "10th_percentile": 14208.4, "90th_percentile": 14208.4, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.840469974; Using new claim; Scope: All Financial Classes; Cases: 2; APCs; 100% Billed, and; Pricing Extension - NM HB XR PRC - 3M $0 RETURN & HAS APC FOR DCH & LESSOR OF; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $113,667.20 @ 12.5% = $14,208.40 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": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.840469974; Using new claim; Scope: All Financial Classes; Cases: 2; APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $113,667.20 @ 12.5% = $14,208.40 due to $0.00 Claim Price", "median_amount": 14208.4, "10th_percentile": 14208.4, "90th_percentile": 14208.4, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.840469974; Using new claim; Scope: All Financial Classes; Cases: 2; APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $113,667.20 @ 12.5% = $14,208.40 due to $0.00 Claim Price" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.840469974; Using new claim; Scope: All Financial Classes; Cases: 2; APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $113,667.20 @ 6.8% = $7,729.37 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": 7729.37, "10th_percentile": 7729.37, "90th_percentile": 7729.37, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.840469974; Using new claim; Scope: All Financial Classes; Cases: 2; APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $113,667.20 @ 6.8% = $7,729.37 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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.840469974; Using new claim; Scope: All Financial Classes; Cases: 2; APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $113,667.20 @ 6.8% = $7,729.37 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": 7729.37, "10th_percentile": 7729.37, "90th_percentile": 7729.37, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.840469974; Using new claim; Scope: All Financial Classes; Cases: 2; APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $113,667.20 @ 6.8% = $7,729.37 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.840469974; Using new claim; Scope: All Financial Classes; Cases: 2; APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $113,667.20 @ 6.8% = $7,729.37 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": 7729.37, "10th_percentile": 7729.37, "90th_percentile": 7729.37, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.840469974; Using new claim; Scope: All Financial Classes; Cases: 2; APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $113,667.20 @ 6.8% = $7,729.37 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 BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_percentage": 88.91, "standard_charge_algorithm": "Additional drugs can be included in reimbursement.", "median_amount": 2719.0, "10th_percentile": 2719.0, "90th_percentile": 2719.0, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_percentage": 88.91, "standard_charge_algorithm": "Additional drugs can be included in reimbursement.", "median_amount": 2719.0, "10th_percentile": 2719.0, "90th_percentile": 2719.0, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_percentage": 55.9, "standard_charge_algorithm": "Additional anesthesia services, drugs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 63539.95, "10th_percentile": 63539.95, "90th_percentile": 63539.95, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_percentage": 33.4, "standard_charge_algorithm": "Additional anesthesia services, drugs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 37964.83, "10th_percentile": 37964.83, "90th_percentile": 37964.83, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 56833.64, "10th_percentile": 56833.64, "90th_percentile": 56833.64, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_percentage": 37.5, "standard_charge_algorithm": "Additional anesthesia services, drugs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 41485.39, "10th_percentile": 41485.39, "90th_percentile": 41485.39, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 90933.76, "10th_percentile": 90933.76, "90th_percentile": 90933.76, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_percentage": 75.2, "standard_charge_algorithm": "Additional anesthesia services, drugs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 82766.21, "10th_percentile": 82766.21, "90th_percentile": 82766.21, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 90933.76, "10th_percentile": 90933.76, "90th_percentile": 90933.76, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 78430.39, "10th_percentile": 78430.39, "90th_percentile": 78430.39, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 85250.44, "10th_percentile": 85250.44, "90th_percentile": 85250.44, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 56833.64, "10th_percentile": 56833.64, "90th_percentile": 56833.64, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_percentage": 65.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 73883.7, "10th_percentile": 73883.7, "90th_percentile": 73883.7, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_percentage": 85.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 96617.14, "10th_percentile": 96617.14, "90th_percentile": 96617.14, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 71610.36, "10th_percentile": 71610.36, "90th_percentile": 71610.36, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_percentage": 90.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 102300.5, "10th_percentile": 102300.5, "90th_percentile": 102300.5, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 113667.2, "10th_percentile": 113667.2, "90th_percentile": 113667.2, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 85250.44, "10th_percentile": 85250.44, "90th_percentile": 85250.44, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_percentage": 64.23, "standard_charge_algorithm": "Additional anesthesia services, drugs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 72518.12, "10th_percentile": 72518.12, "90th_percentile": 72518.12, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 113667.2, "10th_percentile": 113667.2, "90th_percentile": 113667.2, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_percentage": 16.3, "standard_charge_algorithm": "Additional anesthesia services, drugs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 18527.75, "10th_percentile": 18527.75, "90th_percentile": 18527.75, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_percentage": 33.4, "standard_charge_algorithm": "Additional anesthesia services, drugs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 37964.83, "10th_percentile": 37964.83, "90th_percentile": 37964.83, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_percentage": 90.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 102300.5, "10th_percentile": 102300.5, "90th_percentile": 102300.5, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_percentage": 28.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 31826.82, "10th_percentile": 31826.82, "90th_percentile": 31826.82, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_percentage": 28.9, "standard_charge_algorithm": "Additional anesthesia services, drugs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 32849.81, "10th_percentile": 32849.81, "90th_percentile": 32849.81, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_percentage": 28.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 31826.82, "10th_percentile": 31826.82, "90th_percentile": 31826.82, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 3919.5, "standard_charge_algorithm": "Re-evaluated: HLB.840469974; Using new claim; Scope: All Financial Classes; Cases: 2; OP Surgery Group 6; Case Rate @ $3,919.50, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12243.06, "10th_percentile": 12243.06, "90th_percentile": 12243.06, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 3527.5, "standard_charge_algorithm": "Re-evaluated: HLB.840469974; Using new claim; Scope: All Financial Classes; Cases: 2; OP Surgery Group 6; Case Rate @ $3,527.50, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11067.06, "10th_percentile": 11067.06, "90th_percentile": 11067.06, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 1054.5, "standard_charge_algorithm": "Re-evaluated: HLB.840469974; Using new claim; Scope: All Financial Classes; Cases: 2; Amb Surgery Group 4; Case Rate @ $1,054.50, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6674.76, "10th_percentile": 6674.76, "90th_percentile": 6674.76, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 1054.5, "standard_charge_algorithm": "Re-evaluated: HLB.840469974; Using new claim; Scope: All Financial Classes; Cases: 2; Amb Surgery Group 4; Case Rate @ $1,054.50, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6674.76, "10th_percentile": 6674.76, "90th_percentile": 6674.76, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 1160.0, "standard_charge_algorithm": "Re-evaluated: HLB.840469974; Using new claim; Scope: All Financial Classes; Cases: 2; Amb Surgery Group 4; Case Rate @ $1,160.00, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7060.26, "10th_percentile": 7060.26, "90th_percentile": 7060.26, "count": "1 through 10", "methodology": "case rate" } ] } ] }, { "description": "Arthroscopy Hip W/Femoroplasty", "code_information": [ { "code": "CASE-29914", "type": "LOCAL" }, { "code": "29914", "type": "CPT" }, { "code": "0360", "type": "RC" } ], "standard_charges": [ { "minimum": 2109.0, "maximum": 7839.0, "setting": "outpatient", "gross_charge": 106343.74, "discounted_cash": 74440.62, "payers_information": [ { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.713207615; Using new claim; Scope: All Financial Classes; Cases: 28; APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $106,343.75 @ 12.5% = $13,292.97 due to $0.00 Claim Price", "median_amount": 13292.97, "10th_percentile": 13292.97, "90th_percentile": 13292.97, "count": "28", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.713207615; Using new claim; Scope: All Financial Classes; Cases: 28; APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $106,343.75 @ 12.5% = $13,292.97 due to $0.00 Claim Price" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.713207615; Using new claim; Scope: All Financial Classes; Cases: 28; APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $106,343.75 @ 12.5% = $13,292.97 due to $0.00 Claim Price", "median_amount": 13292.97, "10th_percentile": 13292.97, "90th_percentile": 13292.97, "count": "28", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.713207615; Using new claim; Scope: All Financial Classes; Cases: 28; APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $106,343.75 @ 12.5% = $13,292.97 due to $0.00 Claim Price" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.713207615; Using new claim; Scope: All Financial Classes; Cases: 28; APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $106,343.75 @ 6.8% = $7,231.38 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": 7231.38, "10th_percentile": 7231.38, "90th_percentile": 7231.38, "count": "28", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.713207615; Using new claim; Scope: All Financial Classes; Cases: 28; APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $106,343.75 @ 6.8% = $7,231.38 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.713207615; Using new claim; Scope: All Financial Classes; Cases: 28; APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $106,343.75 @ 6.8% = $7,231.38 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": 7231.38, "10th_percentile": 7231.38, "90th_percentile": 7231.38, "count": "28", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.713207615; Using new claim; Scope: All Financial Classes; Cases: 28; APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $106,343.75 @ 6.8% = $7,231.38 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": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_percentage": 120.0, "standard_charge_algorithm": "Re-evaluated: HLB.713207615; Using new claim; Scope: All Financial Classes; Cases: 28; APCs; 120% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 120% = $0.00. Percent of Claim Billed: $106,343.75 @ 12.5% = $13,292.97 due to $0.00 Claim Price", "median_amount": 13292.97, "10th_percentile": 13292.97, "90th_percentile": 13292.97, "count": "28", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.713207615; Using new claim; Scope: All Financial Classes; Cases: 28; APCs; 120% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 120% = $0.00. Percent of Claim Billed: $106,343.75 @ 12.5% = $13,292.97 due to $0.00 Claim Price" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH 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": 53171.91, "10th_percentile": 53171.91, "90th_percentile": 53171.91, "count": "28", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_percentage": 37.5, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 38473.28, "10th_percentile": 38473.28, "90th_percentile": 38473.28, "count": "28", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH 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": 85075.0, "10th_percentile": 85075.0, "90th_percentile": 85075.0, "count": "28", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_percentage": 75.2, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 77116.03, "10th_percentile": 77116.03, "90th_percentile": 77116.03, "count": "28", "methodology": "percent of total billed charges" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH 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": 85075.0, "10th_percentile": 85075.0, "90th_percentile": 85075.0, "count": "28", "methodology": "percent of total billed charges" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 73377.2, "10th_percentile": 73377.2, "90th_percentile": 73377.2, "count": "28", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 79757.84, "10th_percentile": 79757.84, "90th_percentile": 79757.84, "count": "28", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH 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": 53171.91, "10th_percentile": 53171.91, "90th_percentile": 53171.91, "count": "28", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_percentage": 65.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 69123.46, "10th_percentile": 69123.46, "90th_percentile": 69123.46, "count": "28", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_percentage": 85.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 90392.21, "10th_percentile": 90392.21, "90th_percentile": 90392.21, "count": "28", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH 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": 66996.59, "10th_percentile": 66996.59, "90th_percentile": 66996.59, "count": "28", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_percentage": 90.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 95709.41, "10th_percentile": 95709.41, "90th_percentile": 95709.41, "count": "28", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH 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": 106343.75, "10th_percentile": 106343.75, "90th_percentile": 106343.75, "count": "28", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 79757.84, "10th_percentile": 79757.84, "90th_percentile": 79757.84, "count": "28", "methodology": "percent of total billed charges" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH 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": 67449.25, "10th_percentile": 67449.25, "90th_percentile": 67449.25, "count": "28", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH 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": 106343.75, "10th_percentile": 106343.75, "90th_percentile": 106343.75, "count": "28", "methodology": "percent of total billed charges" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 2109.0, "standard_charge_algorithm": "Re-evaluated: HLB.713207615; Using new claim; Scope: All Financial Classes; Cases: 28; Amb Surgery Group 4; Case Rate @ $2,109.00, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5903.06, "10th_percentile": 5903.06, "90th_percentile": 5903.06, "count": "28", "methodology": "case rate" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 7839.0, "standard_charge_algorithm": "Re-evaluated: HLB.713207615; Using new claim; Scope: All Financial Classes; Cases: 28; OP Surgery Group 6; Case Rate @ $7,839.00, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11798.48, "10th_percentile": 11798.48, "90th_percentile": 11798.48, "count": "28", "methodology": "case rate" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 7055.0, "standard_charge_algorithm": "Re-evaluated: HLB.713207615; Using new claim; Scope: All Financial Classes; Cases: 28; OP Surgery Group 6; Case Rate @ $7,055.00, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10622.48, "10th_percentile": 10622.48, "90th_percentile": 10622.48, "count": "28", "methodology": "case rate" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_percentage": 93.0, "standard_charge_algorithm": "Re-evaluated: HLB.713207615; Using new claim; Scope: All Financial Classes; Cases: 28; APCs; 93% Billed, and; Pricing Extension - NM HB XR PRC - 3M $0 RETURN & HAS APC FOR DCH & LESSOR OF; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 93% = $0.00. Percent of Claim Billed: $106,343.75 @ 12.5% = $13,292.97 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": 13292.97, "10th_percentile": 13292.97, "90th_percentile": 13292.97, "count": "28", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.713207615; Using new claim; Scope: All Financial Classes; Cases: 28; APCs; 93% Billed, and; Pricing Extension - NM HB XR PRC - 3M $0 RETURN & HAS APC FOR DCH & LESSOR OF; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 93% = $0.00. Percent of Claim Billed: $106,343.75 @ 12.5% = $13,292.97 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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_percentage": 120.0, "standard_charge_algorithm": "Re-evaluated: HLB.713207615; Using new claim; Scope: All Financial Classes; Cases: 28; APCs; 120% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 120% = $0.00. Percent of Claim Billed: $106,343.75 @ 12.5% = $13,292.97 due to $0.00 Claim Price", "median_amount": 13292.97, "10th_percentile": 13292.97, "90th_percentile": 13292.97, "count": "28", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.713207615; Using new claim; Scope: All Financial Classes; Cases: 28; APCs; 120% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 120% = $0.00. Percent of Claim Billed: $106,343.75 @ 12.5% = $13,292.97 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.713207615; Using new claim; Scope: All Financial Classes; Cases: 28; APCs; 100% Billed, and; Pricing Extension - NM HB XR PRC - 3M $0 RETURN & HAS APC FOR DCH & LESSOR OF; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $106,343.75 @ 12.5% = $13,292.97 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": 13292.97, "10th_percentile": 13292.97, "90th_percentile": 13292.97, "count": "28", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.713207615; Using new claim; Scope: All Financial Classes; Cases: 28; APCs; 100% Billed, and; Pricing Extension - NM HB XR PRC - 3M $0 RETURN & HAS APC FOR DCH & LESSOR OF; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $106,343.75 @ 12.5% = $13,292.97 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": "DCH HUMANA MEDICARE ADVT", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.713207615; Using new claim; Scope: All Financial Classes; Cases: 28; APCs; 100% Billed, and; Pricing Extension - NM HB XR PRC - 3M $0 RETURN & HAS APC FOR DCH & LESSOR OF; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $106,343.75 @ 12.5% = $13,292.97 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": 13292.97, "10th_percentile": 13292.97, "90th_percentile": 13292.97, "count": "28", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.713207615; Using new claim; Scope: All Financial Classes; Cases: 28; APCs; 100% Billed, and; Pricing Extension - NM HB XR PRC - 3M $0 RETURN & HAS APC FOR DCH & LESSOR OF; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $106,343.75 @ 12.5% = $13,292.97 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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.713207615; Using new claim; Scope: All Financial Classes; Cases: 28; APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $106,343.75 @ 6.8% = $7,231.38 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": 7231.38, "10th_percentile": 7231.38, "90th_percentile": 7231.38, "count": "28", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.713207615; Using new claim; Scope: All Financial Classes; Cases: 28; APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $106,343.75 @ 6.8% = $7,231.38 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 BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_percentage": 88.91, "standard_charge_algorithm": "Additional drugs can be included in reimbursement.", "median_amount": 2719.0, "10th_percentile": 2719.0, "90th_percentile": 2719.0, "count": "28", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_percentage": 88.91, "standard_charge_algorithm": "Additional drugs can be included in reimbursement.", "median_amount": 2719.0, "10th_percentile": 2719.0, "90th_percentile": 2719.0, "count": "28", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_percentage": 16.3, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 17334.05, "10th_percentile": 17334.05, "90th_percentile": 17334.05, "count": "28", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_percentage": 33.4, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 35518.81, "10th_percentile": 35518.81, "90th_percentile": 35518.81, "count": "28", "methodology": "percent of total billed charges" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_percentage": 90.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 95709.41, "10th_percentile": 95709.41, "90th_percentile": 95709.41, "count": "28", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_percentage": 28.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 29776.25, "10th_percentile": 29776.25, "90th_percentile": 29776.25, "count": "28", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_percentage": 28.9, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 30733.32, "10th_percentile": 30733.32, "90th_percentile": 30733.32, "count": "28", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_percentage": 28.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 29776.25, "10th_percentile": 29776.25, "90th_percentile": 29776.25, "count": "28", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_percentage": 55.9, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 59446.14, "10th_percentile": 59446.14, "90th_percentile": 59446.14, "count": "28", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_percentage": 33.4, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 35518.81, "10th_percentile": 35518.81, "90th_percentile": 35518.81, "count": "28", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 2109.0, "standard_charge_algorithm": "Re-evaluated: HLB.713207615; Using new claim; Scope: All Financial Classes; Cases: 28; Amb Surgery Group 4; Case Rate @ $2,109.00, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5903.06, "10th_percentile": 5903.06, "90th_percentile": 5903.06, "count": "28", "methodology": "case rate" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 2320.0, "standard_charge_algorithm": "Re-evaluated: HLB.713207615; Using new claim; Scope: All Financial Classes; Cases: 28; Amb Surgery Group 4; Case Rate @ $2,320.00, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6219.56, "10th_percentile": 6219.56, "90th_percentile": 6219.56, "count": "28", "methodology": "case rate" } ] } ] }, { "description": "BACITRACIN ZINC 500 UNIT/GRAM TOP OIPK", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-93165", "type": "CDM" }, { "code": "J3490", "type": "HCPCS" }, { "code": "0637", "type": "RC" }, { "code": "57896-0145-09", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.15, "maximum": 1.0, "setting": "outpatient", "gross_charge": 1.0, "discounted_cash": 0.7, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS 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": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "DCH 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": "DCH 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" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "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": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "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": "DCH 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": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "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": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1.00 @ 12.5% = $0.13 due to $0.00 Claim Price", "median_amount": 0.13, "10th_percentile": 0.13, "90th_percentile": 0.13, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1.00 @ 12.5% = $0.13 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1.00 @ 6.8% = $0.07 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": 0.07, "10th_percentile": 0.07, "90th_percentile": 0.07, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1.00 @ 6.8% = $0.07 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": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1.00 @ 6.8% = $0.07 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": 0.07, "10th_percentile": 0.07, "90th_percentile": 0.07, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1.00 @ 6.8% = $0.07 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1.00 @ 6.8% = $0.07 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": 0.07, "10th_percentile": 0.07, "90th_percentile": 0.07, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1.00 @ 6.8% = $0.07 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": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 0.62, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "Drugs/Agents Default; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "Drugs/Agents Default; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 0.68, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "Drugs/Agents Default; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.68, "10th_percentile": 0.68, "90th_percentile": 0.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.16, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 0.16, "10th_percentile": 0.16, "90th_percentile": 0.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 0.7, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.7, "10th_percentile": 0.7, "90th_percentile": 0.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 0.23, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 0.23, "10th_percentile": 0.23, "90th_percentile": 0.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 0.9, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 0.9, "10th_percentile": 0.9, "90th_percentile": 0.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.15, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.15, "10th_percentile": 0.15, "90th_percentile": 0.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.18, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.18, "10th_percentile": 0.18, "90th_percentile": 0.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.15, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.15, "10th_percentile": 0.15, "90th_percentile": 0.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 0.7, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.7, "10th_percentile": 0.7, "90th_percentile": 0.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 0.56, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.56, "10th_percentile": 0.56, "90th_percentile": 0.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 0.23, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 0.23, "10th_percentile": 0.23, "90th_percentile": 0.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 0.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.5, "10th_percentile": 0.5, "90th_percentile": 0.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH 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": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 0.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 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 DEF; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 0.62, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "Drugs/Agents Default; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "Drugs/Agents Default; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 0.69, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 0.69, "10th_percentile": 0.69, "90th_percentile": 0.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 0.75, "10th_percentile": 0.75, "90th_percentile": 0.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 0.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 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 SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 0.65, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 0.65, "10th_percentile": 0.65, "90th_percentile": 0.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 0.85, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 0.85, "10th_percentile": 0.85, "90th_percentile": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH 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": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 0.9, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 0.9, "10th_percentile": 0.9, "90th_percentile": 0.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 0.75, "10th_percentile": 0.75, "90th_percentile": 0.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH 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": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 0.47, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.47, "10th_percentile": 0.47, "90th_percentile": 0.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 0.53, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.53, "10th_percentile": 0.53, "90th_percentile": 0.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH 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": "MULTIPLAN/PHCS [142]", "plan_name": "DCH 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" } ] } ] }, { "description": "BACLOFEN 5 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-218821", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "52817-0319-10", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.73, "maximum": 4.5, "setting": "outpatient", "gross_charge": 4.5, "discounted_cash": 3.15, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "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": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "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": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "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": "DCH BLUE CROSS 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": "DCH 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": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "DCH 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": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH 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": "GLOBAL EXCEL [1712]", "plan_name": "DCH 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": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "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": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 3.11, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 3.11, "10th_percentile": 3.11, "90th_percentile": 3.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 2.21, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.21, "10th_percentile": 2.21, "90th_percentile": 2.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 0.98, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.98, "10th_percentile": 0.98, "90th_percentile": 0.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH 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": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 3.83, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 3.83, "10th_percentile": 3.83, "90th_percentile": 3.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.73, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 0.73, "10th_percentile": 0.73, "90th_percentile": 0.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 3.06, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.06, "10th_percentile": 3.06, "90th_percentile": 3.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 2.13, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.13, "10th_percentile": 2.13, "90th_percentile": 2.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1.3, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2.52, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.52, "10th_percentile": 2.52, "90th_percentile": 2.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1.27, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.27, "10th_percentile": 1.27, "90th_percentile": 1.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1.26, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.26, "10th_percentile": 1.26, "90th_percentile": 1.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 2.37, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.37, "10th_percentile": 2.37, "90th_percentile": 2.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH 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": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 2.93, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% 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 procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 3.38, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 3.38, "10th_percentile": 3.38, "90th_percentile": 3.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 3.38, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 3.38, "10th_percentile": 3.38, "90th_percentile": 3.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 2.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 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 SRVS; 50% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 2.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 4.05, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% 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 SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 4.05, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% 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 SERVICES; 90% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 3.14, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.14, "10th_percentile": 3.14, "90th_percentile": 3.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 3.14, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.14, "10th_percentile": 3.14, "90th_percentile": 3.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH 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": "DCH 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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 1.62, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.62, "10th_percentile": 1.62, "90th_percentile": 1.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 1.62, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.62, "10th_percentile": 1.62, "90th_percentile": 1.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 2.79, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.79, "10th_percentile": 2.79, "90th_percentile": 2.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 2.79, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.79, "10th_percentile": 2.79, "90th_percentile": 2.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH COMPSYCH", "standard_charge_dollar": 3.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 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 DEF; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH 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" } ] } ] }, { "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": 1.53, "maximum": 10.25, "setting": "outpatient", "gross_charge": 10.25, "discounted_cash": 7.17, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 10.25, "10th_percentile": 10.25, "90th_percentile": 10.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 10.25, "10th_percentile": 10.25, "90th_percentile": 10.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 10.25, "10th_percentile": 10.25, "90th_percentile": 10.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 10.25, "10th_percentile": 10.25, "90th_percentile": 10.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 10.25, "10th_percentile": 10.25, "90th_percentile": 10.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 10.25, "10th_percentile": 10.25, "90th_percentile": 10.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 10.25, "10th_percentile": 10.25, "90th_percentile": 10.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $10.25 @ 12.5% = $1.28 due to $0.00 Claim Price", "median_amount": 1.28, "10th_percentile": 1.28, "90th_percentile": 1.28, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $10.25 @ 12.5% = $1.28 due to $0.00 Claim Price" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $10.25 @ 6.8% = $0.70 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": 0.7, "10th_percentile": 0.7, "90th_percentile": 0.7, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $10.25 @ 6.8% = $0.70 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": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $10.25 @ 6.8% = $0.70 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": 0.7, "10th_percentile": 0.7, "90th_percentile": 0.7, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $10.25 @ 6.8% = $0.70 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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $10.25 @ 6.8% = $0.70 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": 0.7, "10th_percentile": 0.7, "90th_percentile": 0.7, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $10.25 @ 6.8% = $0.70 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 BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 7.15, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.15, "10th_percentile": 7.15, "90th_percentile": 7.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 7.15, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.15, "10th_percentile": 7.15, "90th_percentile": 7.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 6.36, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "Drugs/Agents Default; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "Drugs/Agents Default; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 6.96, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "Drugs/Agents Default; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.96, "10th_percentile": 6.96, "90th_percentile": 6.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 1.67, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 1.67, "10th_percentile": 1.67, "90th_percentile": 1.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 2.39, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 2.39, "10th_percentile": 2.39, "90th_percentile": 2.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 9.23, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% 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 SERVICES; 90% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1.53, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.53, "10th_percentile": 1.53, "90th_percentile": 1.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1.85, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.85, "10th_percentile": 1.85, "90th_percentile": 1.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1.53, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.53, "10th_percentile": 1.53, "90th_percentile": 1.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 5.73, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.73, "10th_percentile": 5.73, "90th_percentile": 5.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 2.39, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 2.39, "10th_percentile": 2.39, "90th_percentile": 2.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 5.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.13, "10th_percentile": 5.13, "90th_percentile": 5.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 8.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 8.2, "10th_percentile": 8.2, "90th_percentile": 8.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 8.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 8.2, "10th_percentile": 8.2, "90th_percentile": 8.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 6.36, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "Drugs/Agents Default; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "Drugs/Agents Default; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 7.07, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% 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; 69% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 7.69, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 7.69, "10th_percentile": 7.69, "90th_percentile": 7.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 5.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 5.13, "10th_percentile": 5.13, "90th_percentile": 5.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 6.66, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 6.66, "10th_percentile": 6.66, "90th_percentile": 6.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 8.71, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 8.71, "10th_percentile": 8.71, "90th_percentile": 8.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 6.46, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 6.46, "10th_percentile": 6.46, "90th_percentile": 6.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 9.23, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% 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 SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 7.69, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 7.69, "10th_percentile": 7.69, "90th_percentile": 7.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 6.58, "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": 6.58, "10th_percentile": 6.58, "90th_percentile": 6.58, "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": "DCH UHC CORE", "standard_charge_dollar": 4.86, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.86, "10th_percentile": 4.86, "90th_percentile": 4.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 5.4, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.4, "10th_percentile": 5.4, "90th_percentile": 5.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 10.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 10.25, "10th_percentile": 10.25, "90th_percentile": 10.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 10.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 10.25, "10th_percentile": 10.25, "90th_percentile": 10.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BAG URINE DRAINAGE 154102", "code_information": [ { "code": "SUP-302799", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 4.06, "maximum": 24.88, "setting": "outpatient", "gross_charge": 24.88, "discounted_cash": 17.42, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 7.04, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.04, "10th_percentile": 7.04, "90th_percentile": 7.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 6.97, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.97, "10th_percentile": 6.97, "90th_percentile": 6.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 13.91, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13.91, "10th_percentile": 13.91, "90th_percentile": 13.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 8.97, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 17.35, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 17.35, "10th_percentile": 17.35, "90th_percentile": 17.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 7.18, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.18, "10th_percentile": 7.18, "90th_percentile": 7.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 22.39, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 22.39, "10th_percentile": 22.39, "90th_percentile": 22.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 22.39, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 22.39, "10th_percentile": 22.39, "90th_percentile": 22.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 24.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 24.88, "10th_percentile": 24.88, "90th_percentile": 24.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 18.66, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 18.66, "10th_percentile": 18.66, "90th_percentile": 18.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 16.89, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.89, "10th_percentile": 16.89, "90th_percentile": 16.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH THE ALLIANCE", "standard_charge_dollar": 15.98, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 15.98, "10th_percentile": 15.98, "90th_percentile": 15.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 12.44, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.44, "10th_percentile": 12.44, "90th_percentile": 12.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 17.17, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 17.17, "10th_percentile": 17.17, "90th_percentile": 17.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 17.35, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 17.35, "10th_percentile": 17.35, "90th_percentile": 17.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH COMPSYCH", "standard_charge_dollar": 19.9, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 19.9, "10th_percentile": 19.9, "90th_percentile": 19.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 4.06, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 4.06, "10th_percentile": 4.06, "90th_percentile": 4.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 15.67, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 15.67, "10th_percentile": 15.67, "90th_percentile": 15.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 8.97, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 5.42, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.42, "10th_percentile": 5.42, "90th_percentile": 5.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 12.19, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.19, "10th_percentile": 12.19, "90th_percentile": 12.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 19.9, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 19.9, "10th_percentile": 19.9, "90th_percentile": 19.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 24.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 24.88, "10th_percentile": 24.88, "90th_percentile": 24.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 13.11, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13.11, "10th_percentile": 13.11, "90th_percentile": 13.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 11.79, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.79, "10th_percentile": 11.79, "90th_percentile": 11.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 21.15, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 21.15, "10th_percentile": 21.15, "90th_percentile": 21.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 12.44, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 12.44, "10th_percentile": 12.44, "90th_percentile": 12.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 18.66, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 18.66, "10th_percentile": 18.66, "90th_percentile": 18.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 16.17, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 16.17, "10th_percentile": 16.17, "90th_percentile": 16.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 15.43, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15.43, "10th_percentile": 15.43, "90th_percentile": 15.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 15.43, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15.43, "10th_percentile": 15.43, "90th_percentile": 15.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 24.88, "10th_percentile": 24.88, "90th_percentile": 24.88, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 24.88, "10th_percentile": 24.88, "90th_percentile": 24.88, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 24.88, "10th_percentile": 24.88, "90th_percentile": 24.88, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 24.88, "10th_percentile": 24.88, "90th_percentile": 24.88, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 24.88, "10th_percentile": 24.88, "90th_percentile": 24.88, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 24.88, "10th_percentile": 24.88, "90th_percentile": 24.88, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 24.88, "10th_percentile": 24.88, "90th_percentile": 24.88, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 24.88, "10th_percentile": 24.88, "90th_percentile": 24.88, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 24.88, "10th_percentile": 24.88, "90th_percentile": 24.88, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 24.88, "10th_percentile": 24.88, "90th_percentile": 24.88, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 24.88, "10th_percentile": 24.88, "90th_percentile": 24.88, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "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": 93.76, "maximum": 629.28, "setting": "outpatient", "gross_charge": 629.28, "discounted_cash": 440.5, "payers_information": [ { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 308.35, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 36.66, "10th_percentile": 36.66, "90th_percentile": 36.66, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 427.28, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 427.28, "10th_percentile": 427.28, "90th_percentile": 427.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 102.57, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 102.57, "10th_percentile": 102.57, "90th_percentile": 102.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 113.27, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 113.27, "10th_percentile": 113.27, "90th_percentile": 113.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 351.77, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 351.77, "10th_percentile": 351.77, "90th_percentile": 351.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 434.2, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 434.2, "10th_percentile": 434.2, "90th_percentile": 434.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 137.18, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.2, "10th_percentile": 20.2, "90th_percentile": 20.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 396.45, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 396.45, "10th_percentile": 396.45, "90th_percentile": 396.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 534.89, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 534.89, "10th_percentile": 534.89, "90th_percentile": 534.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 409.03, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 409.03, "10th_percentile": 409.03, "90th_percentile": 409.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 438.73, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 438.73, "10th_percentile": 438.73, "90th_percentile": 438.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 438.73, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 438.73, "10th_percentile": 438.73, "90th_percentile": 438.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 146.62, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 146.62, "10th_percentile": 146.62, "90th_percentile": 146.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 146.62, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 146.62, "10th_percentile": 146.62, "90th_percentile": 146.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 93.76, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 93.76, "10th_percentile": 93.76, "90th_percentile": 93.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 93.76, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 93.76, "10th_percentile": 93.76, "90th_percentile": 93.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 566.35, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 566.35, "10th_percentile": 566.35, "90th_percentile": 566.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 390.15, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 390.15, "10th_percentile": 390.15, "90th_percentile": 390.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 390.15, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 390.15, "10th_percentile": 390.15, "90th_percentile": 390.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 314.64, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 314.64, "10th_percentile": 314.64, "90th_percentile": 314.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 314.64, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 314.64, "10th_percentile": 314.64, "90th_percentile": 314.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 471.96, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 471.96, "10th_percentile": 471.96, "90th_percentile": 471.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 503.42, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 503.42, "10th_percentile": 503.42, "90th_percentile": 503.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 503.42, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 503.42, "10th_percentile": 503.42, "90th_percentile": 503.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $629.28 @ 6.8% = $42.79 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": 42.79, "10th_percentile": 42.79, "90th_percentile": 42.79, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $629.28 @ 6.8% = $42.79 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": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $629.28 @ 6.8% = $42.79 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": 42.79, "10th_percentile": 42.79, "90th_percentile": 42.79, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $629.28 @ 6.8% = $42.79 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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $629.28 @ 6.8% = $42.79 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": 42.79, "10th_percentile": 42.79, "90th_percentile": 42.79, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $629.28 @ 6.8% = $42.79 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": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $629.28 @ 12.5% = $78.66 due to $0.00 Claim Price", "median_amount": 78.66, "10th_percentile": 78.66, "90th_percentile": 78.66, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $629.28 @ 12.5% = $78.66 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 629.28, "10th_percentile": 629.28, "90th_percentile": 629.28, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 629.28, "10th_percentile": 629.28, "90th_percentile": 629.28, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 629.28, "10th_percentile": 629.28, "90th_percentile": 629.28, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 629.28, "10th_percentile": 629.28, "90th_percentile": 629.28, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 629.28, "10th_percentile": 629.28, "90th_percentile": 629.28, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 629.28, "10th_percentile": 629.28, "90th_percentile": 629.28, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 331.63, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.36, "10th_percentile": 16.36, "90th_percentile": 16.36, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 298.28, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 298.28, "10th_percentile": 298.28, "90th_percentile": 298.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 404.19, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 404.19, "10th_percentile": 404.19, "90th_percentile": 404.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 471.96, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 471.96, "10th_percentile": 471.96, "90th_percentile": 471.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 629.28, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 629.28, "10th_percentile": 629.28, "90th_percentile": 629.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 629.28, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 629.28, "10th_percentile": 629.28, "90th_percentile": 629.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 566.35, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 566.35, "10th_percentile": 566.35, "90th_percentile": 566.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 629.28, "10th_percentile": 629.28, "90th_percentile": 629.28, "count": "0", "methodology": "other", "additional_payer_notes": "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": 64.43, "maximum": 395.27, "setting": "outpatient", "gross_charge": 395.27, "discounted_cash": 276.69, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 245.07, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 245.07, "10th_percentile": 245.07, "90th_percentile": 245.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 114.0, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 114.0, "10th_percentile": 114.0, "90th_percentile": 114.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 275.58, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 275.58, "10th_percentile": 275.58, "90th_percentile": 275.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 111.78, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 111.78, "10th_percentile": 111.78, "90th_percentile": 111.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 220.96, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 220.96, "10th_percentile": 220.96, "90th_percentile": 220.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 142.46, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 142.46, "10th_percentile": 142.46, "90th_percentile": 142.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 110.68, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 110.68, "10th_percentile": 110.68, "90th_percentile": 110.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 355.74, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 355.74, "10th_percentile": 355.74, "90th_percentile": 355.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 268.39, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 268.39, "10th_percentile": 268.39, "90th_percentile": 268.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 275.58, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 275.58, "10th_percentile": 275.58, "90th_percentile": 275.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 64.43, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 64.43, "10th_percentile": 64.43, "90th_percentile": 64.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 142.46, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 142.46, "10th_percentile": 142.46, "90th_percentile": 142.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 395.27, "10th_percentile": 395.27, "90th_percentile": 395.27, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 395.27, "10th_percentile": 395.27, "90th_percentile": 395.27, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 395.27, "10th_percentile": 395.27, "90th_percentile": 395.27, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 395.27, "10th_percentile": 395.27, "90th_percentile": 395.27, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 395.27, "10th_percentile": 395.27, "90th_percentile": 395.27, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 245.07, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 245.07, "10th_percentile": 245.07, "90th_percentile": 245.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 355.74, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 355.74, "10th_percentile": 355.74, "90th_percentile": 355.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 197.64, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 197.64, "10th_percentile": 197.64, "90th_percentile": 197.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 256.93, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 256.93, "10th_percentile": 256.93, "90th_percentile": 256.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 296.45, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 296.45, "10th_percentile": 296.45, "90th_percentile": 296.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 335.98, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 335.98, "10th_percentile": 335.98, "90th_percentile": 335.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 187.36, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 187.36, "10th_percentile": 187.36, "90th_percentile": 187.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 395.27, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 395.27, "10th_percentile": 395.27, "90th_percentile": 395.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 208.31, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 208.31, "10th_percentile": 208.31, "90th_percentile": 208.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 249.02, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 249.02, "10th_percentile": 249.02, "90th_percentile": 249.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 86.17, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 86.17, "10th_percentile": 86.17, "90th_percentile": 86.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 193.68, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 193.68, "10th_percentile": 193.68, "90th_percentile": 193.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 316.22, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 316.22, "10th_percentile": 316.22, "90th_percentile": 316.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 197.64, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 197.64, "10th_percentile": 197.64, "90th_percentile": 197.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 316.22, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 316.22, "10th_percentile": 316.22, "90th_percentile": 316.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 253.88, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 253.88, "10th_percentile": 253.88, "90th_percentile": 253.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 296.45, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 296.45, "10th_percentile": 296.45, "90th_percentile": 296.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 272.74, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 272.74, "10th_percentile": 272.74, "90th_percentile": 272.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 395.27, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 395.27, "10th_percentile": 395.27, "90th_percentile": 395.27, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 395.27, "10th_percentile": 395.27, "90th_percentile": 395.27, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 395.27, "10th_percentile": 395.27, "90th_percentile": 395.27, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 395.27, "10th_percentile": 395.27, "90th_percentile": 395.27, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 395.27, "10th_percentile": 395.27, "90th_percentile": 395.27, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 395.27, "10th_percentile": 395.27, "90th_percentile": 395.27, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 395.27, "10th_percentile": 395.27, "90th_percentile": 395.27, "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": 4.44, "maximum": 27.21, "setting": "outpatient", "gross_charge": 27.21, "discounted_cash": 19.05, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 7.69, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.69, "10th_percentile": 7.69, "90th_percentile": 7.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 7.62, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.62, "10th_percentile": 7.62, "90th_percentile": 7.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 15.21, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15.21, "10th_percentile": 15.21, "90th_percentile": 15.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 9.81, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.81, "10th_percentile": 9.81, "90th_percentile": 9.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 18.97, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 18.97, "10th_percentile": 18.97, "90th_percentile": 18.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 7.85, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.85, "10th_percentile": 7.85, "90th_percentile": 7.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 24.49, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 24.49, "10th_percentile": 24.49, "90th_percentile": 24.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 24.49, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 24.49, "10th_percentile": 24.49, "90th_percentile": 24.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 27.21, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 27.21, "10th_percentile": 27.21, "90th_percentile": 27.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 20.41, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 20.41, "10th_percentile": 20.41, "90th_percentile": 20.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 18.48, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 18.48, "10th_percentile": 18.48, "90th_percentile": 18.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH THE ALLIANCE", "standard_charge_dollar": 17.48, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 17.48, "10th_percentile": 17.48, "90th_percentile": 17.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 13.61, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13.61, "10th_percentile": 13.61, "90th_percentile": 13.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 18.77, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 18.77, "10th_percentile": 18.77, "90th_percentile": 18.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 18.97, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 18.97, "10th_percentile": 18.97, "90th_percentile": 18.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH COMPSYCH", "standard_charge_dollar": 21.77, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 21.77, "10th_percentile": 21.77, "90th_percentile": 21.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 4.44, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 4.44, "10th_percentile": 4.44, "90th_percentile": 4.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 17.14, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 17.14, "10th_percentile": 17.14, "90th_percentile": 17.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 9.81, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.81, "10th_percentile": 9.81, "90th_percentile": 9.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 5.93, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.93, "10th_percentile": 5.93, "90th_percentile": 5.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 13.33, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13.33, "10th_percentile": 13.33, "90th_percentile": 13.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 21.77, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 21.77, "10th_percentile": 21.77, "90th_percentile": 21.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 27.21, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 27.21, "10th_percentile": 27.21, "90th_percentile": 27.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 14.34, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14.34, "10th_percentile": 14.34, "90th_percentile": 14.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 12.9, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.9, "10th_percentile": 12.9, "90th_percentile": 12.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 23.13, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 23.13, "10th_percentile": 23.13, "90th_percentile": 23.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 13.61, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 13.61, "10th_percentile": 13.61, "90th_percentile": 13.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 20.41, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 20.41, "10th_percentile": 20.41, "90th_percentile": 20.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 17.69, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 17.69, "10th_percentile": 17.69, "90th_percentile": 17.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 16.87, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.87, "10th_percentile": 16.87, "90th_percentile": 16.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 16.87, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.87, "10th_percentile": 16.87, "90th_percentile": 16.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 27.21, "10th_percentile": 27.21, "90th_percentile": 27.21, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 27.21, "10th_percentile": 27.21, "90th_percentile": 27.21, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 27.21, "10th_percentile": 27.21, "90th_percentile": 27.21, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 27.21, "10th_percentile": 27.21, "90th_percentile": 27.21, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 27.21, "10th_percentile": 27.21, "90th_percentile": 27.21, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 27.21, "10th_percentile": 27.21, "90th_percentile": 27.21, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 27.21, "10th_percentile": 27.21, "90th_percentile": 27.21, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 27.21, "10th_percentile": 27.21, "90th_percentile": 27.21, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 27.21, "10th_percentile": 27.21, "90th_percentile": 27.21, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 27.21, "10th_percentile": 27.21, "90th_percentile": 27.21, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 27.21, "10th_percentile": 27.21, "90th_percentile": 27.21, "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": 249.06, "maximum": 1671.53, "setting": "outpatient", "gross_charge": 1671.53, "discounted_cash": 1170.07, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1671.53, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1671.53, "10th_percentile": 1671.53, "90th_percentile": 1671.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 1036.35, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1036.35, "10th_percentile": 1036.35, "90th_percentile": 1036.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 1134.97, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1134.97, "10th_percentile": 1134.97, "90th_percentile": 1134.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 272.46, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 272.46, "10th_percentile": 272.46, "90th_percentile": 272.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 1165.39, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1165.39, "10th_percentile": 1165.39, "90th_percentile": 1165.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 389.47, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 389.47, "10th_percentile": 389.47, "90th_percentile": 389.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 1504.38, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 1504.38, "10th_percentile": 1504.38, "90th_percentile": 1504.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 249.06, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 249.06, "10th_percentile": 249.06, "90th_percentile": 249.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 300.88, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 300.88, "10th_percentile": 300.88, "90th_percentile": 300.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 249.06, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 249.06, "10th_percentile": 249.06, "90th_percentile": 249.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 1165.39, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1165.39, "10th_percentile": 1165.39, "90th_percentile": 1165.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 934.39, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 934.39, "10th_percentile": 934.39, "90th_percentile": 934.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 389.47, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 389.47, "10th_percentile": 389.47, "90th_percentile": 389.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 835.77, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 835.77, "10th_percentile": 835.77, "90th_percentile": 835.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 364.39, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 364.39, "10th_percentile": 364.39, "90th_percentile": 364.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1337.22, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 1337.22, "10th_percentile": 1337.22, "90th_percentile": 1337.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 819.05, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 819.05, "10th_percentile": 819.05, "90th_percentile": 819.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 1337.22, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 1337.22, "10th_percentile": 1337.22, "90th_percentile": 1337.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 1036.35, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1036.35, "10th_percentile": 1036.35, "90th_percentile": 1036.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 1153.36, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 1153.36, "10th_percentile": 1153.36, "90th_percentile": 1153.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 1253.65, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 1253.65, "10th_percentile": 1253.65, "90th_percentile": 1253.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 835.77, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 835.77, "10th_percentile": 835.77, "90th_percentile": 835.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 1086.49, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 1086.49, "10th_percentile": 1086.49, "90th_percentile": 1086.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 1420.8, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 1420.8, "10th_percentile": 1420.8, "90th_percentile": 1420.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 1053.06, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 1053.06, "10th_percentile": 1053.06, "90th_percentile": 1053.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 1504.38, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 1504.38, "10th_percentile": 1504.38, "90th_percentile": 1504.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 1253.65, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 1253.65, "10th_percentile": 1253.65, "90th_percentile": 1253.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 1073.62, "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": 1073.62, "10th_percentile": 1073.62, "90th_percentile": 1073.62, "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": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 792.31, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 792.31, "10th_percentile": 792.31, "90th_percentile": 792.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 880.9, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 880.9, "10th_percentile": 880.9, "90th_percentile": 880.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1671.53, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1671.53, "10th_percentile": 1671.53, "90th_percentile": 1671.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,671.53 @ 12.5% = $208.94 due to $0.00 Claim Price", "median_amount": 208.94, "10th_percentile": 208.94, "90th_percentile": 208.94, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,671.53 @ 12.5% = $208.94 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,671.53 @ 6.8% = $113.66 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": 113.66, "10th_percentile": 113.66, "90th_percentile": 113.66, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,671.53 @ 6.8% = $113.66 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": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,671.53 @ 6.8% = $113.66 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": 113.66, "10th_percentile": 113.66, "90th_percentile": 113.66, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,671.53 @ 6.8% = $113.66 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,671.53 @ 6.8% = $113.66 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": 113.66, "10th_percentile": 113.66, "90th_percentile": 113.66, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,671.53 @ 6.8% = $113.66 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": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 1671.53, "10th_percentile": 1671.53, "90th_percentile": 1671.53, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1671.53, "10th_percentile": 1671.53, "90th_percentile": 1671.53, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1671.53, "10th_percentile": 1671.53, "90th_percentile": 1671.53, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1671.53, "10th_percentile": 1671.53, "90th_percentile": 1671.53, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1671.53, "10th_percentile": 1671.53, "90th_percentile": 1671.53, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1671.53, "10th_percentile": 1671.53, "90th_percentile": 1671.53, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1671.53, "10th_percentile": 1671.53, "90th_percentile": 1671.53, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "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": 308.1, "maximum": 1890.18, "setting": "outpatient", "gross_charge": 1890.18, "discounted_cash": 1323.13, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 534.54, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 534.54, "10th_percentile": 534.54, "90th_percentile": 534.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 529.25, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 529.25, "10th_percentile": 529.25, "90th_percentile": 529.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1056.61, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1056.61, "10th_percentile": 1056.61, "90th_percentile": 1056.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 681.22, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 681.22, "10th_percentile": 681.22, "90th_percentile": 681.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 1317.83, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1317.83, "10th_percentile": 1317.83, "90th_percentile": 1317.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 545.13, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 545.13, "10th_percentile": 545.13, "90th_percentile": 545.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 1701.16, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 1701.16, "10th_percentile": 1701.16, "90th_percentile": 1701.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 1701.16, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 1701.16, "10th_percentile": 1701.16, "90th_percentile": 1701.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1890.18, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1890.18, "10th_percentile": 1890.18, "90th_percentile": 1890.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 1417.64, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 1417.64, "10th_percentile": 1417.64, "90th_percentile": 1417.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 1283.43, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1283.43, "10th_percentile": 1283.43, "90th_percentile": 1283.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH THE ALLIANCE", "standard_charge_dollar": 1214.06, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1214.06, "10th_percentile": 1214.06, "90th_percentile": 1214.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 945.09, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 945.09, "10th_percentile": 945.09, "90th_percentile": 945.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 1304.22, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 1304.22, "10th_percentile": 1304.22, "90th_percentile": 1304.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 1317.83, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1317.83, "10th_percentile": 1317.83, "90th_percentile": 1317.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH COMPSYCH", "standard_charge_dollar": 1512.14, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 1512.14, "10th_percentile": 1512.14, "90th_percentile": 1512.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 308.1, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 308.1, "10th_percentile": 308.1, "90th_percentile": 308.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 1190.81, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 1190.81, "10th_percentile": 1190.81, "90th_percentile": 1190.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 681.22, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 681.22, "10th_percentile": 681.22, "90th_percentile": 681.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 412.06, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 412.06, "10th_percentile": 412.06, "90th_percentile": 412.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 926.19, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 926.19, "10th_percentile": 926.19, "90th_percentile": 926.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1512.14, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 1512.14, "10th_percentile": 1512.14, "90th_percentile": 1512.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1890.18, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1890.18, "10th_percentile": 1890.18, "90th_percentile": 1890.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 996.12, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 996.12, "10th_percentile": 996.12, "90th_percentile": 996.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 895.95, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 895.95, "10th_percentile": 895.95, "90th_percentile": 895.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 1606.65, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 1606.65, "10th_percentile": 1606.65, "90th_percentile": 1606.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 945.09, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 945.09, "10th_percentile": 945.09, "90th_percentile": 945.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 1417.64, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 1417.64, "10th_percentile": 1417.64, "90th_percentile": 1417.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 1228.62, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 1228.62, "10th_percentile": 1228.62, "90th_percentile": 1228.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 1171.91, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1171.91, "10th_percentile": 1171.91, "90th_percentile": 1171.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 1171.91, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1171.91, "10th_percentile": 1171.91, "90th_percentile": 1171.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 1890.18, "10th_percentile": 1890.18, "90th_percentile": 1890.18, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1890.18, "10th_percentile": 1890.18, "90th_percentile": 1890.18, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1890.18, "10th_percentile": 1890.18, "90th_percentile": 1890.18, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1890.18, "10th_percentile": 1890.18, "90th_percentile": 1890.18, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1890.18, "10th_percentile": 1890.18, "90th_percentile": 1890.18, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1890.18, "10th_percentile": 1890.18, "90th_percentile": 1890.18, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1890.18, "10th_percentile": 1890.18, "90th_percentile": 1890.18, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1890.18, "10th_percentile": 1890.18, "90th_percentile": 1890.18, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1890.18, "10th_percentile": 1890.18, "90th_percentile": 1890.18, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1890.18, "10th_percentile": 1890.18, "90th_percentile": 1890.18, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1890.18, "10th_percentile": 1890.18, "90th_percentile": 1890.18, "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": 425.85, "maximum": 2612.56, "setting": "outpatient", "gross_charge": 2612.56, "discounted_cash": 1828.79, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 753.46, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 753.46, "10th_percentile": 753.46, "90th_percentile": 753.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 731.52, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 731.52, "10th_percentile": 731.52, "90th_percentile": 731.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 941.57, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 941.57, "10th_percentile": 941.57, "90th_percentile": 941.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1460.42, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1460.42, "10th_percentile": 1460.42, "90th_percentile": 1460.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 738.83, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 738.83, "10th_percentile": 738.83, "90th_percentile": 738.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 1821.48, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1821.48, "10th_percentile": 1821.48, "90th_percentile": 1821.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 1619.79, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1619.79, "10th_percentile": 1619.79, "90th_percentile": 1619.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 1619.79, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1619.79, "10th_percentile": 1619.79, "90th_percentile": 1619.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 2351.3, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 2351.3, "10th_percentile": 2351.3, "90th_percentile": 2351.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 2351.3, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 2351.3, "10th_percentile": 2351.3, "90th_percentile": 2351.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 1306.28, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 1306.28, "10th_percentile": 1306.28, "90th_percentile": 1306.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 1698.16, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 1698.16, "10th_percentile": 1698.16, "90th_percentile": 1698.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 1959.42, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 1959.42, "10th_percentile": 1959.42, "90th_percentile": 1959.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 2220.68, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 2220.68, "10th_percentile": 2220.68, "90th_percentile": 2220.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 941.57, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 941.57, "10th_percentile": 941.57, "90th_percentile": 941.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 1238.35, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1238.35, "10th_percentile": 1238.35, "90th_percentile": 1238.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2612.56, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2612.56, "10th_percentile": 2612.56, "90th_percentile": 2612.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 1376.82, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1376.82, "10th_percentile": 1376.82, "90th_percentile": 1376.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 1645.91, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 1645.91, "10th_percentile": 1645.91, "90th_percentile": 1645.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 569.54, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 569.54, "10th_percentile": 569.54, "90th_percentile": 569.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 1280.15, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1280.15, "10th_percentile": 1280.15, "90th_percentile": 1280.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 2090.05, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 2090.05, "10th_percentile": 2090.05, "90th_percentile": 2090.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 1306.28, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1306.28, "10th_percentile": 1306.28, "90th_percentile": 1306.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 425.85, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 425.85, "10th_percentile": 425.85, "90th_percentile": 425.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 2090.05, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 2090.05, "10th_percentile": 2090.05, "90th_percentile": 2090.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 1678.05, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1678.05, "10th_percentile": 1678.05, "90th_percentile": 1678.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 1959.42, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 1959.42, "10th_percentile": 1959.42, "90th_percentile": 1959.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 1821.48, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1821.48, "10th_percentile": 1821.48, "90th_percentile": 1821.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 1802.67, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 1802.67, "10th_percentile": 1802.67, "90th_percentile": 1802.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 1773.93, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1773.93, "10th_percentile": 1773.93, "90th_percentile": 1773.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2612.56, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2612.56, "10th_percentile": 2612.56, "90th_percentile": 2612.56, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 2612.56, "10th_percentile": 2612.56, "90th_percentile": 2612.56, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2612.56, "10th_percentile": 2612.56, "90th_percentile": 2612.56, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2612.56, "10th_percentile": 2612.56, "90th_percentile": 2612.56, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2612.56, "10th_percentile": 2612.56, "90th_percentile": 2612.56, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2612.56, "10th_percentile": 2612.56, "90th_percentile": 2612.56, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2612.56, "10th_percentile": 2612.56, "90th_percentile": 2612.56, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2612.56, "10th_percentile": 2612.56, "90th_percentile": 2612.56, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2612.56, "10th_percentile": 2612.56, "90th_percentile": 2612.56, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2612.56, "10th_percentile": 2612.56, "90th_percentile": 2612.56, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2612.56, "10th_percentile": 2612.56, "90th_percentile": 2612.56, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2612.56, "10th_percentile": 2612.56, "90th_percentile": 2612.56, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BEARING TIB 79/83MM 10MM KN PSTR STBL VANGUARD VIVACIT-E", "code_information": [ { "code": "SUP-309898", "type": "CDM" }, { "code": "C1776", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 924.63, "maximum": 6294.26, "setting": "outpatient", "gross_charge": 6294.26, "discounted_cash": 4405.98, "payers_information": [ { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $6,294.26 @ 6.8% = $428.01 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": 824.68, "10th_percentile": 824.68, "90th_percentile": 824.68, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $6,294.26 @ 6.8% = $428.01 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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $6,294.26 @ 6.8% = $428.01 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": 824.68, "10th_percentile": 824.68, "90th_percentile": 824.68, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $6,294.26 @ 6.8% = $428.01 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $6,294.26 @ 6.8% = $428.01 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": 824.68, "10th_percentile": 824.68, "90th_percentile": 824.68, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $6,294.26 @ 6.8% = $428.01 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": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 6294.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 6294.26, "10th_percentile": 6294.26, "90th_percentile": 6294.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6294.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6294.26, "10th_percentile": 6294.26, "90th_percentile": 6294.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 5035.41, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 5035.41, "10th_percentile": 5035.41, "90th_percentile": 5035.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 1466.56, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 1466.56, "10th_percentile": 1466.56, "90th_percentile": 1466.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 3084.19, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3084.19, "10th_percentile": 3084.19, "90th_percentile": 3084.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 4720.7, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 4720.7, "10th_percentile": 4720.7, "90th_percentile": 4720.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 3965.38, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 3965.38, "10th_percentile": 3965.38, "90th_percentile": 3965.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 2983.48, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2983.48, "10th_percentile": 2983.48, "90th_percentile": 2983.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 5035.41, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 5035.41, "10th_percentile": 5035.41, "90th_percentile": 5035.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 4388.36, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4388.36, "10th_percentile": 4388.36, "90th_percentile": 4388.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 1025.96, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 1025.96, "10th_percentile": 1025.96, "90th_percentile": 1025.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 4343.04, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 4343.04, "10th_percentile": 4343.04, "90th_percentile": 4343.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 3147.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3147.13, "10th_percentile": 3147.13, "90th_percentile": 3147.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 1372.15, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1372.15, "10th_percentile": 1372.15, "90th_percentile": 1372.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH THE ALLIANCE", "standard_charge_dollar": 4042.8, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 4042.8, "10th_percentile": 4042.8, "90th_percentile": 4042.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 3317.08, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3488.32, "10th_percentile": 3488.32, "90th_percentile": 3488.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 4091.27, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 4091.27, "10th_percentile": 4091.27, "90th_percentile": 4091.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 5350.12, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 5350.12, "10th_percentile": 5350.12, "90th_percentile": 5350.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 4720.7, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 4720.7, "10th_percentile": 4720.7, "90th_percentile": 4720.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 3147.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 3147.13, "10th_percentile": 3147.13, "90th_percentile": 3147.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 5664.83, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 5664.83, "10th_percentile": 5664.83, "90th_percentile": 5664.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 5664.83, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 5664.83, "10th_percentile": 5664.83, "90th_percentile": 5664.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 4388.36, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4388.36, "10th_percentile": 4388.36, "90th_percentile": 4388.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1132.97, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1132.97, "10th_percentile": 1132.97, "90th_percentile": 1132.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 3518.49, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3518.49, "10th_percentile": 3518.49, "90th_percentile": 3518.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 1466.56, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 1466.56, "10th_percentile": 1466.56, "90th_percentile": 1466.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 937.84, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 937.84, "10th_percentile": 937.84, "90th_percentile": 937.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 937.84, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 937.84, "10th_percentile": 937.84, "90th_percentile": 937.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 924.63, "standard_charge_percentage": 14.69, "standard_charge_algorithm": "Implant/Prosthetic Rev Code 278; 14.69% Billed", "median_amount": 924.63, "10th_percentile": 924.63, "90th_percentile": 924.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Implant/Prosthetic Rev Code 278; 14.69% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 924.63, "standard_charge_percentage": 14.69, "standard_charge_algorithm": "Implant/Prosthetic Rev Code 278; 14.69% Billed", "median_amount": 924.63, "10th_percentile": 924.63, "90th_percentile": 924.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Implant/Prosthetic Rev Code 278; 14.69% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 924.63, "standard_charge_percentage": 14.69, "standard_charge_algorithm": "Implant/Prosthetic Rev Code 278; 14.69% Billed", "median_amount": 924.63, "10th_percentile": 924.63, "90th_percentile": 924.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Implant/Prosthetic Rev Code 278; 14.69% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $6,294.26 @ 12.5% = $786.78 due to $0.00 Claim Price", "median_amount": 786.78, "10th_percentile": 786.78, "90th_percentile": 786.78, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $6,294.26 @ 12.5% = $786.78 due to $0.00 Claim Price" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 6294.26, "10th_percentile": 6294.26, "90th_percentile": 6294.26, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6294.26, "10th_percentile": 6294.26, "90th_percentile": 6294.26, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6294.26, "10th_percentile": 6294.26, "90th_percentile": 6294.26, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6294.26, "10th_percentile": 6294.26, "90th_percentile": 6294.26, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6294.26, "10th_percentile": 6294.26, "90th_percentile": 6294.26, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6294.26, "10th_percentile": 6294.26, "90th_percentile": 6294.26, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6294.26, "10th_percentile": 6294.26, "90th_percentile": 6294.26, "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": 11253.81, "setting": "inpatient", "gross_charge": 39090.0, "discounted_cash": 27363.0, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.855151453; Using historical claim(s); Scope: All Financial Classes; Cases: 2; All IP Services; 100% Billed", "median_amount": 39090.0, "10th_percentile": 39090.0, "90th_percentile": 39090.0, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.855151453; Using historical claim(s); Scope: All Financial Classes; Cases: 2; All IP Services - OON; 100% Billed", "median_amount": 39090.0, "10th_percentile": 39090.0, "90th_percentile": 39090.0, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_percentage": 85.0, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, therapy services, and other services can be included in reimbursement.", "median_amount": 33226.5, "10th_percentile": 33226.5, "90th_percentile": 33226.5, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_percentage": 65.0, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, therapy services, and other services can be included in reimbursement.", "median_amount": 25408.5, "10th_percentile": 25408.5, "90th_percentile": 25408.5, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_percentage": 90.0, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, therapy services, and other services can be included in reimbursement.", "median_amount": 35181.0, "10th_percentile": 35181.0, "90th_percentile": 35181.0, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Re-evaluated: HLB.855151453; Using historical claim(s); Scope: All Financial Classes; Cases: 2; Inpatient Services; 63% Billed", "median_amount": 24626.7, "10th_percentile": 24626.7, "90th_percentile": 24626.7, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, therapy services, and other services can be included in reimbursement.", "median_amount": 29317.5, "10th_percentile": 29317.5, "90th_percentile": 29317.5, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, therapy services, and other services can be included in reimbursement.", "median_amount": 19545.0, "10th_percentile": 19545.0, "90th_percentile": 19545.0, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_percentage": 67.8, "standard_charge_algorithm": "Re-evaluated: HLB.855151453; Using historical claim(s); Scope: All Financial Classes; Cases: 2; All Inpatient Services; 67.8% Billed", "median_amount": 26503.02, "10th_percentile": 26503.02, "90th_percentile": 26503.02, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, therapy services, and other services can be included in reimbursement.", "median_amount": 31272.0, "10th_percentile": 31272.0, "90th_percentile": 31272.0, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_percentage": 16.3, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, therapy services, and other services can be included in reimbursement.", "median_amount": 6371.7, "10th_percentile": 6371.7, "90th_percentile": 6371.7, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_percentage": 49.0, "standard_charge_algorithm": "Re-evaluated: HLB.855151453; Using historical claim(s); Scope: All Financial Classes; Cases: 2; IP Services. ADP RATE (for patient estimates only); 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19154.1, "10th_percentile": 19154.1, "90th_percentile": 19154.1, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_percentage": 90.0, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, therapy services, and other services can be included in reimbursement.", "median_amount": 35181.0, "10th_percentile": 35181.0, "90th_percentile": 35181.0, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.855151453; Using historical claim(s); Scope: All Financial Classes; Cases: 2; Inpatient (Non Covered - Verify Coverage); 100% Billed", "median_amount": 39090.0, "10th_percentile": 39090.0, "90th_percentile": 39090.0, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 11253.81, "standard_charge_algorithm": "Re-evaluated: HLB.855151453; Using historical claim(s); Scope: All Financial Classes; Cases: 2; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.7220, Rate: 15,587.00, and; Pricing Extension - NM HB XR PRC - DCH 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": 11253.81, "10th_percentile": 11253.81, "90th_percentile": 11253.81, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 5430.16, "standard_charge_algorithm": "Re-evaluated: HLB.855151453; Using historical claim(s); Scope: All Financial Classes; Cases: 2; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.7220, Rate: 7,521.00, and; Pricing Extension - NM HB XR PRC - DCH 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": 5430.16, "10th_percentile": 5430.16, "90th_percentile": 5430.16, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 11253.81, "standard_charge_algorithm": "Re-evaluated: HLB.855151453; Using historical claim(s); Scope: All Financial Classes; Cases: 2; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.7220, Rate: 15,587.00, and; Pricing Extension - NM HB XR PRC - DCH 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": 11253.81, "10th_percentile": 11253.81, "90th_percentile": 11253.81, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 6484.28, "standard_charge_algorithm": "Re-evaluated: HLB.855151453; Using historical claim(s); Scope: All Financial Classes; Cases: 2; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.7220, Rate: 8,981.00, and; Pricing Extension - NM HB XR PRC - DCH 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": 6484.28, "10th_percentile": 6484.28, "90th_percentile": 6484.28, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 5358.68, "standard_charge_algorithm": "Re-evaluated: HLB.855151453; Using historical claim(s); Scope: All Financial Classes; Cases: 2; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.7220, Rate: 7,422.00, and; Pricing Extension - NM HB XR PRC - DCH BCBS CHOICE SELECT CASE RATE W/OUTLIER S*", "median_amount": 5358.68, "10th_percentile": 5358.68, "90th_percentile": 5358.68, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 5466.26, "standard_charge_algorithm": "Re-evaluated: HLB.855151453; Using historical claim(s); Scope: All Financial Classes; Cases: 2; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.7220, Rate: 7,571.00, and; Pricing Extension - NM HB XR PRC - DCH 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": 5466.26, "10th_percentile": 5466.26, "90th_percentile": 5466.26, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 5430.16, "standard_charge_algorithm": "Re-evaluated: HLB.855151453; Using historical claim(s); Scope: All Financial Classes; Cases: 2; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.7220, Rate: 7,521.00, and; Pricing Extension - NM HB XR PRC - DCH 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": 5430.16, "10th_percentile": 5430.16, "90th_percentile": 5430.16, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_dollar": 5137.63, "standard_charge_algorithm": "Re-evaluated: HLB.855151453; Using historical claim(s); Scope: All Financial Classes; Cases: 2; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 0.72, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $6,021.34; Total: $6,021.34", "median_amount": 6021.34, "10th_percentile": 6021.34, "90th_percentile": 6021.34, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.855151453; Using historical claim(s); Scope: All Financial Classes; Cases: 2; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 0.72, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $6,021.34; Total: $6,021.34" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "DCH HUMANA MEDICARE ADVT", "standard_charge_dollar": 5137.63, "standard_charge_algorithm": "Re-evaluated: HLB.855151453; Using historical claim(s); Scope: All Financial Classes; Cases: 2; 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: $5,546.03; Total: $5,546.03 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5546.03, "10th_percentile": 5546.03, "90th_percentile": 5546.03, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.855151453; Using historical claim(s); Scope: All Financial Classes; Cases: 2; 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: $5,546.03; Total: $5,546.03 Paid at contractual rate, which is the lesser 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": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_dollar": 5137.63, "standard_charge_algorithm": "Re-evaluated: HLB.855151453; Using historical claim(s); Scope: All Financial Classes; Cases: 2; 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: $5,580.60; Percentage applied: 97.00%; Total: $5,413.18 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5413.18, "10th_percentile": 5413.18, "90th_percentile": 5413.18, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.855151453; Using historical claim(s); Scope: All Financial Classes; Cases: 2; 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: $5,580.60; Percentage applied: 97.00%; Total: $5,413.18 Paid at contractual rate, which is the lesser of contractual and 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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 5137.63, "standard_charge_algorithm": "Re-evaluated: HLB.855151453; Using historical claim(s); Scope: All Financial Classes; Cases: 2; 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: $5,580.60; Total: $5,580.60 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5580.6, "10th_percentile": 5580.6, "90th_percentile": 5580.6, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.855151453; Using historical claim(s); Scope: All Financial Classes; Cases: 2; 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: $5,580.60; Total: $5,580.60 Paid at contractual rate, which is 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 20 % MM AEROSOL SPRAY", "drug_information": { "unit": 57.0, "type": "GR" }, "code_information": [ { "code": "RX-4080000155", "type": "CDM" }, { "code": "25000000", "type": "LOCAL" }, { "code": "0250", "type": "RC" }, { "code": "00699-3100-02", "type": "NDC" } ], "standard_charges": [ { "minimum": 102.16, "maximum": 626.75, "setting": "outpatient", "gross_charge": 626.75, "discounted_cash": 438.72, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 626.75, "10th_percentile": 626.75, "90th_percentile": 626.75, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 626.75, "10th_percentile": 626.75, "90th_percentile": 626.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 626.75, "10th_percentile": 626.75, "90th_percentile": 626.75, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 626.75, "10th_percentile": 626.75, "90th_percentile": 626.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 626.75, "10th_percentile": 626.75, "90th_percentile": 626.75, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 626.75, "10th_percentile": 626.75, "90th_percentile": 626.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 626.75, "10th_percentile": 626.75, "90th_percentile": 626.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 626.75, "10th_percentile": 626.75, "90th_percentile": 626.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 626.75, "10th_percentile": 626.75, "90th_percentile": 626.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 626.75, "10th_percentile": 626.75, "90th_percentile": 626.75, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 626.75, "10th_percentile": 626.75, "90th_percentile": 626.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 388.59, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 388.59, "10th_percentile": 388.59, "90th_percentile": 388.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 425.56, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 425.56, "10th_percentile": 425.56, "90th_percentile": 425.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 102.16, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 102.16, "10th_percentile": 102.16, "90th_percentile": 102.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 436.97, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 436.97, "10th_percentile": 436.97, "90th_percentile": 436.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 225.88, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 225.88, "10th_percentile": 225.88, "90th_percentile": 225.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 564.08, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 564.08, "10th_percentile": 564.08, "90th_percentile": 564.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 180.75, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 180.75, "10th_percentile": 180.75, "90th_percentile": 180.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 177.24, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 177.24, "10th_percentile": 177.24, "90th_percentile": 177.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 175.49, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 175.49, "10th_percentile": 175.49, "90th_percentile": 175.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 436.97, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 436.97, "10th_percentile": 436.97, "90th_percentile": 436.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 350.35, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 350.35, "10th_percentile": 350.35, "90th_percentile": 350.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 225.88, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 225.88, "10th_percentile": 225.88, "90th_percentile": 225.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 313.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 313.38, "10th_percentile": 313.38, "90th_percentile": 313.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 136.63, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 136.63, "10th_percentile": 136.63, "90th_percentile": 136.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 501.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 501.4, "10th_percentile": 501.4, "90th_percentile": 501.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 307.11, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 307.11, "10th_percentile": 307.11, "90th_percentile": 307.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 501.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 501.4, "10th_percentile": 501.4, "90th_percentile": 501.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 388.59, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 388.59, "10th_percentile": 388.59, "90th_percentile": 388.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 432.46, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 432.46, "10th_percentile": 432.46, "90th_percentile": 432.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 470.06, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 470.06, "10th_percentile": 470.06, "90th_percentile": 470.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 313.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 313.38, "10th_percentile": 313.38, "90th_percentile": 313.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 407.39, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 407.39, "10th_percentile": 407.39, "90th_percentile": 407.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 532.74, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 532.74, "10th_percentile": 532.74, "90th_percentile": 532.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 394.85, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 394.85, "10th_percentile": 394.85, "90th_percentile": 394.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 564.08, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 564.08, "10th_percentile": 564.08, "90th_percentile": 564.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 626.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 626.75, "10th_percentile": 626.75, "90th_percentile": 626.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 470.06, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 470.06, "10th_percentile": 470.06, "90th_percentile": 470.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 402.56, "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": 402.56, "10th_percentile": 402.56, "90th_percentile": 402.56, "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": "DCH UHC CORE", "standard_charge_dollar": 297.08, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 297.08, "10th_percentile": 297.08, "90th_percentile": 297.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 330.3, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 330.3, "10th_percentile": 330.3, "90th_percentile": 330.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 626.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 626.75, "10th_percentile": 626.75, "90th_percentile": 626.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 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": 100.97, "maximum": 619.45, "setting": "outpatient", "gross_charge": 619.45, "discounted_cash": 433.61, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 557.51, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 557.51, "10th_percentile": 557.51, "90th_percentile": 557.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 402.64, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 402.64, "10th_percentile": 402.64, "90th_percentile": 402.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 526.53, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 526.53, "10th_percentile": 526.53, "90th_percentile": 526.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 293.62, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 293.62, "10th_percentile": 293.62, "90th_percentile": 293.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 619.45, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 619.45, "10th_percentile": 619.45, "90th_percentile": 619.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 326.45, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 326.45, "10th_percentile": 326.45, "90th_percentile": 326.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 390.25, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 390.25, "10th_percentile": 390.25, "90th_percentile": 390.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 397.87, "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": 397.87, "10th_percentile": 397.87, "90th_percentile": 397.87, "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": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 464.59, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 464.59, "10th_percentile": 464.59, "90th_percentile": 464.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 619.45, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 619.45, "10th_percentile": 619.45, "90th_percentile": 619.45, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 619.45, "10th_percentile": 619.45, "90th_percentile": 619.45, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 619.45, "10th_percentile": 619.45, "90th_percentile": 619.45, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 619.45, "10th_percentile": 619.45, "90th_percentile": 619.45, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 175.18, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 175.18, "10th_percentile": 175.18, "90th_percentile": 175.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 173.45, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 173.45, "10th_percentile": 173.45, "90th_percentile": 173.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 346.27, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 346.27, "10th_percentile": 346.27, "90th_percentile": 346.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 223.25, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 223.25, "10th_percentile": 223.25, "90th_percentile": 223.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 431.88, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 431.88, "10th_percentile": 431.88, "90th_percentile": 431.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 178.65, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 178.65, "10th_percentile": 178.65, "90th_percentile": 178.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 557.51, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 557.51, "10th_percentile": 557.51, "90th_percentile": 557.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 420.61, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 420.61, "10th_percentile": 420.61, "90th_percentile": 420.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 309.73, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 309.73, "10th_percentile": 309.73, "90th_percentile": 309.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 427.42, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 427.42, "10th_percentile": 427.42, "90th_percentile": 427.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 431.88, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 431.88, "10th_percentile": 431.88, "90th_percentile": 431.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH COMPSYCH", "standard_charge_dollar": 495.56, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 495.56, "10th_percentile": 495.56, "90th_percentile": 495.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 100.97, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 100.97, "10th_percentile": 100.97, "90th_percentile": 100.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 223.25, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 223.25, "10th_percentile": 223.25, "90th_percentile": 223.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 135.04, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 135.04, "10th_percentile": 135.04, "90th_percentile": 135.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 303.53, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 303.53, "10th_percentile": 303.53, "90th_percentile": 303.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 495.56, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 495.56, "10th_percentile": 495.56, "90th_percentile": 495.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 309.73, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 309.73, "10th_percentile": 309.73, "90th_percentile": 309.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 464.59, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 464.59, "10th_percentile": 464.59, "90th_percentile": 464.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 384.06, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 384.06, "10th_percentile": 384.06, "90th_percentile": 384.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 384.06, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 384.06, "10th_percentile": 384.06, "90th_percentile": 384.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 619.45, "10th_percentile": 619.45, "90th_percentile": 619.45, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 619.45, "10th_percentile": 619.45, "90th_percentile": 619.45, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 619.45, "10th_percentile": 619.45, "90th_percentile": 619.45, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 619.45, "10th_percentile": 619.45, "90th_percentile": 619.45, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 619.45, "10th_percentile": 619.45, "90th_percentile": 619.45, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 619.45, "10th_percentile": 619.45, "90th_percentile": 619.45, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 619.45, "10th_percentile": 619.45, "90th_percentile": 619.45, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 619.45, "10th_percentile": 619.45, "90th_percentile": 619.45, "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": 13606.12, "maximum": 91316.25, "setting": "outpatient", "gross_charge": 91316.25, "discounted_cash": 63921.37, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 91316.25, "10th_percentile": 91316.25, "90th_percentile": 91316.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 91316.25, "10th_percentile": 91316.25, "90th_percentile": 91316.25, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 91316.25, "10th_percentile": 91316.25, "90th_percentile": 91316.25, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 91316.25, "10th_percentile": 91316.25, "90th_percentile": 91316.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $91,316.25 @ 6.8% = $6,209.51 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": 6209.51, "10th_percentile": 6209.51, "90th_percentile": 6209.51, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $91,316.25 @ 6.8% = $6,209.51 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": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $91,316.25 @ 6.8% = $6,209.51 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": 6209.51, "10th_percentile": 6209.51, "90th_percentile": 6209.51, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $91,316.25 @ 6.8% = $6,209.51 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 BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 21276.69, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 21276.69, "10th_percentile": 21276.69, "90th_percentile": 21276.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 21276.69, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 21276.69, "10th_percentile": 21276.69, "90th_percentile": 21276.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 13606.12, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13606.12, "10th_percentile": 13606.12, "90th_percentile": 13606.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 13606.12, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13606.12, "10th_percentile": 13606.12, "90th_percentile": 13606.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 63665.69, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 63665.69, "10th_percentile": 63665.69, "90th_percentile": 63665.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 63665.69, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 63665.69, "10th_percentile": 63665.69, "90th_percentile": 63665.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 82184.63, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 82184.63, "10th_percentile": 82184.63, "90th_percentile": 82184.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 45658.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 45658.13, "10th_percentile": 45658.13, "90th_percentile": 45658.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 73053.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 73053.0, "10th_percentile": 73053.0, "90th_percentile": 73053.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 63008.21, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 63008.21, "10th_percentile": 63008.21, "90th_percentile": 63008.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 73053.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 73053.0, "10th_percentile": 73053.0, "90th_percentile": 73053.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 51045.78, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 51045.78, "10th_percentile": 51045.78, "90th_percentile": 51045.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 14884.55, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 14884.55, "10th_percentile": 14884.55, "90th_percentile": 14884.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 16436.93, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16436.93, "10th_percentile": 16436.93, "90th_percentile": 16436.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 91316.25, "10th_percentile": 91316.25, "90th_percentile": 91316.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 91316.25, "10th_percentile": 91316.25, "90th_percentile": 91316.25, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 91316.25, "10th_percentile": 91316.25, "90th_percentile": 91316.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $91,316.25 @ 12.5% = $11,414.53 due to $0.00 Claim Price", "median_amount": 11414.53, "10th_percentile": 11414.53, "90th_percentile": 11414.53, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $91,316.25 @ 12.5% = $11,414.53 due to $0.00 Claim Price" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $91,316.25 @ 6.8% = $6,209.51 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": 6209.51, "10th_percentile": 6209.51, "90th_percentile": 6209.51, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $91,316.25 @ 6.8% = $6,209.51 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": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 82184.63, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 82184.63, "10th_percentile": 82184.63, "90th_percentile": 82184.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 77618.81, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 77618.81, "10th_percentile": 77618.81, "90th_percentile": 77618.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 45658.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 45658.13, "10th_percentile": 45658.13, "90th_percentile": 45658.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 68487.19, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 68487.19, "10th_percentile": 68487.19, "90th_percentile": 68487.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 59355.56, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 59355.56, "10th_percentile": 59355.56, "90th_percentile": 59355.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 57529.24, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 57529.24, "10th_percentile": 57529.24, "90th_percentile": 57529.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 68487.19, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 68487.19, "10th_percentile": 68487.19, "90th_percentile": 68487.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 91316.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 91316.25, "10th_percentile": 91316.25, "90th_percentile": 91316.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 91316.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 91316.25, "10th_percentile": 91316.25, "90th_percentile": 91316.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BIOPATCH DRESSING (4150)", "code_information": [ { "code": "SUP-304467", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 9.61, "maximum": 58.93, "setting": "outpatient", "gross_charge": 58.93, "discounted_cash": 41.25, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 17.0, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 17.0, "10th_percentile": 17.0, "90th_percentile": 17.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 16.5, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.5, "10th_percentile": 16.5, "90th_percentile": 16.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 21.24, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 21.24, "10th_percentile": 21.24, "90th_percentile": 21.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 32.94, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 32.94, "10th_percentile": 32.94, "90th_percentile": 32.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 16.67, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.67, "10th_percentile": 16.67, "90th_percentile": 16.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 41.09, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 41.09, "10th_percentile": 41.09, "90th_percentile": 41.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 36.54, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 36.54, "10th_percentile": 36.54, "90th_percentile": 36.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 36.54, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 36.54, "10th_percentile": 36.54, "90th_percentile": 36.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 53.04, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 53.04, "10th_percentile": 53.04, "90th_percentile": 53.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 29.47, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 29.47, "10th_percentile": 29.47, "90th_percentile": 29.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 38.3, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 38.3, "10th_percentile": 38.3, "90th_percentile": 38.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 44.2, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 44.2, "10th_percentile": 44.2, "90th_percentile": 44.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 50.09, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 50.09, "10th_percentile": 50.09, "90th_percentile": 50.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 21.24, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 21.24, "10th_percentile": 21.24, "90th_percentile": 21.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 37.13, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 37.13, "10th_percentile": 37.13, "90th_percentile": 37.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 12.85, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.85, "10th_percentile": 12.85, "90th_percentile": 12.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 28.88, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 28.88, "10th_percentile": 28.88, "90th_percentile": 28.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 47.14, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 47.14, "10th_percentile": 47.14, "90th_percentile": 47.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 29.47, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 29.47, "10th_percentile": 29.47, "90th_percentile": 29.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 9.61, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 9.61, "10th_percentile": 9.61, "90th_percentile": 9.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 47.14, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 47.14, "10th_percentile": 47.14, "90th_percentile": 47.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 41.09, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 41.09, "10th_percentile": 41.09, "90th_percentile": 41.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 40.66, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 40.66, "10th_percentile": 40.66, "90th_percentile": 40.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 40.01, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 40.01, "10th_percentile": 40.01, "90th_percentile": 40.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 58.93, "10th_percentile": 58.93, "90th_percentile": 58.93, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 58.93, "10th_percentile": 58.93, "90th_percentile": 58.93, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 58.93, "10th_percentile": 58.93, "90th_percentile": 58.93, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 58.93, "10th_percentile": 58.93, "90th_percentile": 58.93, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 58.93, "10th_percentile": 58.93, "90th_percentile": 58.93, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 58.93, "10th_percentile": 58.93, "90th_percentile": 58.93, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 58.93, "10th_percentile": 58.93, "90th_percentile": 58.93, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 58.93, "10th_percentile": 58.93, "90th_percentile": 58.93, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 53.04, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 53.04, "10th_percentile": 53.04, "90th_percentile": 53.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 58.93, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 58.93, "10th_percentile": 58.93, "90th_percentile": 58.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 44.2, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 44.2, "10th_percentile": 44.2, "90th_percentile": 44.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 37.85, "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": 37.85, "10th_percentile": 37.85, "90th_percentile": 37.85, "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": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 58.93, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 58.93, "10th_percentile": 58.93, "90th_percentile": 58.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 31.06, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 31.06, "10th_percentile": 31.06, "90th_percentile": 31.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 27.93, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 27.93, "10th_percentile": 27.93, "90th_percentile": 27.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 58.93, "10th_percentile": 58.93, "90th_percentile": 58.93, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 58.93, "10th_percentile": 58.93, "90th_percentile": 58.93, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 58.93, "10th_percentile": 58.93, "90th_percentile": 58.93, "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": 28974.67, "setting": "inpatient", "gross_charge": 84741.43, "discounted_cash": 59319.0, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_percentage": 90.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 76176.38, "10th_percentile": 76176.38, "90th_percentile": 76176.38, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_percentage": 90.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 76176.38, "10th_percentile": 76176.38, "90th_percentile": 76176.38, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 67712.35, "10th_percentile": 67712.35, "90th_percentile": 67712.35, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_percentage": 16.3, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 13796.41, "10th_percentile": 13796.41, "90th_percentile": 13796.41, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Re-evaluated: HLB.793278665; Using historical claim(s); Scope: All Financial Classes; Cases: 4; Inpatient Services; 63% Billed", "median_amount": 53323.47, "10th_percentile": 53323.47, "90th_percentile": 53323.47, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_percentage": 67.8, "standard_charge_algorithm": "Re-evaluated: HLB.793278665; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All Inpatient Services; 67.8% Billed", "median_amount": 57386.21, "10th_percentile": 57386.21, "90th_percentile": 57386.21, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_percentage": 49.0, "standard_charge_algorithm": "Re-evaluated: HLB.793278665; Using historical claim(s); Scope: All Financial Classes; Cases: 4; IP Services. ADP RATE (for patient estimates only); 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 41473.81, "10th_percentile": 41473.81, "90th_percentile": 41473.81, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 63480.32, "10th_percentile": 63480.32, "90th_percentile": 63480.32, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_percentage": 65.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 55016.28, "10th_percentile": 55016.28, "90th_percentile": 55016.28, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 42320.22, "10th_percentile": 42320.22, "90th_percentile": 42320.22, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_percentage": 85.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 71944.37, "10th_percentile": 71944.37, "90th_percentile": 71944.37, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.793278665; Using historical claim(s); Scope: All Financial Classes; Cases: 4; Inpatient (Non Covered - Verify Coverage); 100% Billed", "median_amount": 84640.43, "10th_percentile": 84640.43, "90th_percentile": 84640.43, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 28974.67, "standard_charge_algorithm": "Re-evaluated: HLB.793278665; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.8589, Rate: 15,587.00, and; Pricing Extension - NM HB XR PRC - DCH 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": 28974.67, "10th_percentile": 28974.67, "90th_percentile": 28974.67, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 13796.76, "standard_charge_algorithm": "Re-evaluated: HLB.793278665; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.8589, Rate: 7,422.00, and; Pricing Extension - NM HB XR PRC - DCH BCBS CHOICE SELECT CASE RATE W/OUTLIER S*", "median_amount": 13796.76, "10th_percentile": 13796.76, "90th_percentile": 13796.76, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 14073.73, "standard_charge_algorithm": "Re-evaluated: HLB.793278665; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.8589, Rate: 7,571.00, and; Pricing Extension - NM HB XR PRC - DCH 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": 14073.73, "10th_percentile": 14073.73, "90th_percentile": 14073.73, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 16694.78, "standard_charge_algorithm": "Re-evaluated: HLB.793278665; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.8589, Rate: 8,981.00, and; Pricing Extension - NM HB XR PRC - DCH 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": 16694.78, "10th_percentile": 16694.78, "90th_percentile": 16694.78, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 13980.79, "standard_charge_algorithm": "Re-evaluated: HLB.793278665; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.8589, Rate: 7,521.00, and; Pricing Extension - NM HB XR PRC - DCH 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": 13980.79, "10th_percentile": 13980.79, "90th_percentile": 13980.79, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 13980.79, "standard_charge_algorithm": "Re-evaluated: HLB.793278665; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.8589, Rate: 7,521.00, and; Pricing Extension - NM HB XR PRC - DCH 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": 13980.79, "10th_percentile": 13980.79, "90th_percentile": 13980.79, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 28974.67, "standard_charge_algorithm": "Re-evaluated: HLB.793278665; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.8589, Rate: 15,587.00, and; Pricing Extension - NM HB XR PRC - DCH 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": 28974.67, "10th_percentile": 28974.67, "90th_percentile": 28974.67, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_dollar": 13227.62, "standard_charge_algorithm": "Re-evaluated: HLB.793278665; Using historical claim(s); Scope: All Financial Classes; Cases: 4; 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. Transfer payment: $11,537.61; Percentage applied: 97.00%; Total: $11,191.48 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11191.48, "10th_percentile": 11191.48, "90th_percentile": 11191.48, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.793278665; Using historical claim(s); Scope: All Financial Classes; Cases: 4; 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. Transfer payment: $11,537.61; Percentage applied: 97.00%; Total: $11,191.48 Paid at contractual rate, which is the lesser of contractual and 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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 13227.62, "standard_charge_algorithm": "Re-evaluated: HLB.793278665; Using historical claim(s); Scope: All Financial Classes; Cases: 4; 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. Transfer payment: $11,537.61; Total: $11,537.61 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11537.61, "10th_percentile": 11537.61, "90th_percentile": 11537.61, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.793278665; Using historical claim(s); Scope: All Financial Classes; Cases: 4; 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. Transfer payment: $11,537.61; Total: $11,537.61 Paid at contractual rate, which is the lesser of 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": "DCH HUMANA MEDICARE ADVT", "standard_charge_dollar": 13227.62, "standard_charge_algorithm": "Re-evaluated: HLB.793278665; Using historical claim(s); Scope: All Financial Classes; Cases: 4; 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. Transfer payment: $11,466.14; Total: $11,466.14 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11466.14, "10th_percentile": 11466.14, "90th_percentile": 11466.14, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.793278665; Using historical claim(s); Scope: All Financial Classes; Cases: 4; 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. Transfer payment: $11,466.14; Total: $11,466.14 Paid at contractual rate, which is the lesser 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": "DCH MEDICARE", "standard_charge_dollar": 13227.62, "standard_charge_algorithm": "Re-evaluated: HLB.793278665; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.86, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Transfer payment: $12,448.82; Total: $12,448.82", "median_amount": 12448.82, "10th_percentile": 12448.82, "90th_percentile": 12448.82, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.793278665; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.86, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Transfer payment: $12,448.82; Total: $12,448.82" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.793278665; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services; 100% Billed", "median_amount": 84640.43, "10th_percentile": 84640.43, "90th_percentile": 84640.43, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.793278665; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services - OON; 100% Billed", "median_amount": 84640.43, "10th_percentile": 84640.43, "90th_percentile": 84640.43, "count": "1 through 10", "methodology": "percent of total billed charges" } ] } ] }, { "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": 0.41, "maximum": 2.75, "setting": "outpatient", "gross_charge": 2.75, "discounted_cash": 1.92, "payers_information": [ { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $2.75 @ 12.5% = $0.34 due to $0.00 Claim Price", "median_amount": 0.34, "10th_percentile": 0.34, "90th_percentile": 0.34, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $2.75 @ 12.5% = $0.34 due to $0.00 Claim Price" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $2.75 @ 6.8% = $0.19 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": 0.19, "10th_percentile": 0.19, "90th_percentile": 0.19, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $2.75 @ 6.8% = $0.19 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": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $2.75 @ 6.8% = $0.19 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": 0.19, "10th_percentile": 0.19, "90th_percentile": 0.19, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $2.75 @ 6.8% = $0.19 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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $2.75 @ 6.8% = $0.19 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": 0.19, "10th_percentile": 0.19, "90th_percentile": 0.19, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $2.75 @ 6.8% = $0.19 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": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 1.71, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "Drugs/Agents Default; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "Drugs/Agents Default; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 1.87, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "Drugs/Agents Default; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "Drugs/Agents Default; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.45, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 0.45, "10th_percentile": 0.45, "90th_percentile": 0.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 1.92, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.92, "10th_percentile": 1.92, "90th_percentile": 1.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 0.64, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% 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 Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 2.48, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 2.48, "10th_percentile": 2.48, "90th_percentile": 2.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.41, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.5, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.41, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 1.92, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.92, "10th_percentile": 1.92, "90th_percentile": 1.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1.54, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.54, "10th_percentile": 1.54, "90th_percentile": 1.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 0.64, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% 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 Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 1.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.38, "10th_percentile": 1.38, "90th_percentile": 1.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 2.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 2.2, "10th_percentile": 2.2, "90th_percentile": 2.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 2.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 2.2, "10th_percentile": 2.2, "90th_percentile": 2.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 1.71, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "Drugs/Agents Default; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "Drugs/Agents Default; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 1.9, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 1.9, "10th_percentile": 1.9, "90th_percentile": 1.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 2.06, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 2.06, "10th_percentile": 2.06, "90th_percentile": 2.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 1.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 1.38, "10th_percentile": 1.38, "90th_percentile": 1.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 1.79, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 1.79, "10th_percentile": 1.79, "90th_percentile": 1.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 2.34, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 2.34, "10th_percentile": 2.34, "90th_percentile": 2.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 1.73, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 1.73, "10th_percentile": 1.73, "90th_percentile": 1.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 2.48, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 2.48, "10th_percentile": 2.48, "90th_percentile": 2.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 2.06, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 2.06, "10th_percentile": 2.06, "90th_percentile": 2.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 1.77, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1.77, "10th_percentile": 1.77, "90th_percentile": 1.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 1.3, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.3, "10th_percentile": 1.3, "90th_percentile": 1.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 1.45, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.45, "10th_percentile": 1.45, "90th_percentile": 1.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" } ] } ] }, { "description": "BIT DRILL 1.5X85MM 310.15", "code_information": [ { "code": "SUP-161406", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 102.63, "maximum": 629.61, "setting": "outpatient", "gross_charge": 629.61, "discounted_cash": 440.73, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 390.36, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 390.36, "10th_percentile": 390.36, "90th_percentile": 390.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 390.36, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 390.36, "10th_percentile": 390.36, "90th_percentile": 390.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 181.58, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 181.58, "10th_percentile": 181.58, "90th_percentile": 181.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 438.96, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 438.96, "10th_percentile": 438.96, "90th_percentile": 438.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 178.05, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 178.05, "10th_percentile": 178.05, "90th_percentile": 178.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 351.95, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 351.95, "10th_percentile": 351.95, "90th_percentile": 351.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 226.91, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 226.91, "10th_percentile": 226.91, "90th_percentile": 226.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 176.29, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 176.29, "10th_percentile": 176.29, "90th_percentile": 176.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 566.65, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 566.65, "10th_percentile": 566.65, "90th_percentile": 566.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 566.65, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 566.65, "10th_percentile": 566.65, "90th_percentile": 566.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 314.81, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 314.81, "10th_percentile": 314.81, "90th_percentile": 314.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 409.25, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 409.25, "10th_percentile": 409.25, "90th_percentile": 409.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 472.21, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 472.21, "10th_percentile": 472.21, "90th_percentile": 472.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 535.17, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 535.17, "10th_percentile": 535.17, "90th_percentile": 535.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 427.51, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 427.51, "10th_percentile": 427.51, "90th_percentile": 427.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 629.61, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 629.61, "10th_percentile": 629.61, "90th_percentile": 629.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 503.69, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 503.69, "10th_percentile": 503.69, "90th_percentile": 503.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 298.44, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 298.44, "10th_percentile": 298.44, "90th_percentile": 298.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 331.8, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 331.8, "10th_percentile": 331.8, "90th_percentile": 331.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 629.61, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 629.61, "10th_percentile": 629.61, "90th_percentile": 629.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 404.4, "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": 404.4, "10th_percentile": 404.4, "90th_percentile": 404.4, "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": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 472.21, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 472.21, "10th_percentile": 472.21, "90th_percentile": 472.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 137.25, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 137.25, "10th_percentile": 137.25, "90th_percentile": 137.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 503.69, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 503.69, "10th_percentile": 503.69, "90th_percentile": 503.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 308.51, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 308.51, "10th_percentile": 308.51, "90th_percentile": 308.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 314.81, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 314.81, "10th_percentile": 314.81, "90th_percentile": 314.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 438.96, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 438.96, "10th_percentile": 438.96, "90th_percentile": 438.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 434.43, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 434.43, "10th_percentile": 434.43, "90th_percentile": 434.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 102.63, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 102.63, "10th_percentile": 102.63, "90th_percentile": 102.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 226.91, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 226.91, "10th_percentile": 226.91, "90th_percentile": 226.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 396.65, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 396.65, "10th_percentile": 396.65, "90th_percentile": 396.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 629.61, "10th_percentile": 629.61, "90th_percentile": 629.61, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 629.61, "10th_percentile": 629.61, "90th_percentile": 629.61, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 629.61, "10th_percentile": 629.61, "90th_percentile": 629.61, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 629.61, "10th_percentile": 629.61, "90th_percentile": 629.61, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 629.61, "10th_percentile": 629.61, "90th_percentile": 629.61, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 629.61, "10th_percentile": 629.61, "90th_percentile": 629.61, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 629.61, "10th_percentile": 629.61, "90th_percentile": 629.61, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 629.61, "10th_percentile": 629.61, "90th_percentile": 629.61, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 629.61, "10th_percentile": 629.61, "90th_percentile": 629.61, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 629.61, "10th_percentile": 629.61, "90th_percentile": 629.61, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 629.61, "10th_percentile": 629.61, "90th_percentile": 629.61, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BIT DRILL 1.6X95MM CANN SELF TAPPING COMPRESS DRILL-1.6/095C", "code_information": [ { "code": "SUP-344794", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 238.28, "maximum": 1461.85, "setting": "outpatient", "gross_charge": 1461.85, "discounted_cash": 1023.29, "payers_information": [ { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 906.35, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 906.35, "10th_percentile": 906.35, "90th_percentile": 906.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 1315.67, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 1315.67, "10th_percentile": 1315.67, "90th_percentile": 1315.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 730.93, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 730.93, "10th_percentile": 730.93, "90th_percentile": 730.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 950.2, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 950.2, "10th_percentile": 950.2, "90th_percentile": 950.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 1096.39, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 1096.39, "10th_percentile": 1096.39, "90th_percentile": 1096.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 1242.57, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 1242.57, "10th_percentile": 1242.57, "90th_percentile": 1242.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 692.92, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 692.92, "10th_percentile": 692.92, "90th_percentile": 692.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1461.85, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1461.85, "10th_percentile": 1461.85, "90th_percentile": 1461.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 770.39, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 770.39, "10th_percentile": 770.39, "90th_percentile": 770.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 920.97, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 920.97, "10th_percentile": 920.97, "90th_percentile": 920.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 318.68, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 318.68, "10th_percentile": 318.68, "90th_percentile": 318.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 716.31, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 716.31, "10th_percentile": 716.31, "90th_percentile": 716.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1169.48, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 1169.48, "10th_percentile": 1169.48, "90th_percentile": 1169.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 730.93, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 730.93, "10th_percentile": 730.93, "90th_percentile": 730.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 1169.48, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 1169.48, "10th_percentile": 1169.48, "90th_percentile": 1169.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 938.95, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 938.95, "10th_percentile": 938.95, "90th_percentile": 938.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - 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": "DCH PHCS", "standard_charge_dollar": 1096.39, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 1096.39, "10th_percentile": 1096.39, "90th_percentile": 1096.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 1008.68, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 1008.68, "10th_percentile": 1008.68, "90th_percentile": 1008.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1461.85, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1461.85, "10th_percentile": 1461.85, "90th_percentile": 1461.85, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 1461.85, "10th_percentile": 1461.85, "90th_percentile": 1461.85, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1461.85, "10th_percentile": 1461.85, "90th_percentile": 1461.85, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1461.85, "10th_percentile": 1461.85, "90th_percentile": 1461.85, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1461.85, "10th_percentile": 1461.85, "90th_percentile": 1461.85, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1461.85, "10th_percentile": 1461.85, "90th_percentile": 1461.85, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1461.85, "10th_percentile": 1461.85, "90th_percentile": 1461.85, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 906.35, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 906.35, "10th_percentile": 906.35, "90th_percentile": 906.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 421.6, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 421.6, "10th_percentile": 421.6, "90th_percentile": 421.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 1019.2, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1019.2, "10th_percentile": 1019.2, "90th_percentile": 1019.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 413.41, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 413.41, "10th_percentile": 413.41, "90th_percentile": 413.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 817.17, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 817.17, "10th_percentile": 817.17, "90th_percentile": 817.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 526.85, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 526.85, "10th_percentile": 526.85, "90th_percentile": 526.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 409.32, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 409.32, "10th_percentile": 409.32, "90th_percentile": 409.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 1315.67, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 1315.67, "10th_percentile": 1315.67, "90th_percentile": 1315.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 992.6, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 992.6, "10th_percentile": 992.6, "90th_percentile": 992.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 1019.2, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1019.2, "10th_percentile": 1019.2, "90th_percentile": 1019.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 238.28, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 238.28, "10th_percentile": 238.28, "90th_percentile": 238.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 526.85, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 526.85, "10th_percentile": 526.85, "90th_percentile": 526.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1461.85, "10th_percentile": 1461.85, "90th_percentile": 1461.85, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1461.85, "10th_percentile": 1461.85, "90th_percentile": 1461.85, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1461.85, "10th_percentile": 1461.85, "90th_percentile": 1461.85, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1461.85, "10th_percentile": 1461.85, "90th_percentile": 1461.85, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1461.85, "10th_percentile": 1461.85, "90th_percentile": 1461.85, "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": 296.38, "maximum": 1818.26, "setting": "outpatient", "gross_charge": 1818.26, "discounted_cash": 1272.78, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 524.39, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 524.39, "10th_percentile": 524.39, "90th_percentile": 524.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 509.11, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 509.11, "10th_percentile": 509.11, "90th_percentile": 509.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 655.3, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 655.3, "10th_percentile": 655.3, "90th_percentile": 655.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1016.41, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1016.41, "10th_percentile": 1016.41, "90th_percentile": 1016.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 514.2, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 514.2, "10th_percentile": 514.2, "90th_percentile": 514.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 1267.69, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1267.69, "10th_percentile": 1267.69, "90th_percentile": 1267.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 1127.32, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1127.32, "10th_percentile": 1127.32, "90th_percentile": 1127.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 1127.32, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1127.32, "10th_percentile": 1127.32, "90th_percentile": 1127.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 1636.43, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 1636.43, "10th_percentile": 1636.43, "90th_percentile": 1636.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 909.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 909.13, "10th_percentile": 909.13, "90th_percentile": 909.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 1181.87, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 1181.87, "10th_percentile": 1181.87, "90th_percentile": 1181.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 1363.7, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 1363.7, "10th_percentile": 1363.7, "90th_percentile": 1363.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 1545.52, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 1545.52, "10th_percentile": 1545.52, "90th_percentile": 1545.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 655.3, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 655.3, "10th_percentile": 655.3, "90th_percentile": 655.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 396.38, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 396.38, "10th_percentile": 396.38, "90th_percentile": 396.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 890.95, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 890.95, "10th_percentile": 890.95, "90th_percentile": 890.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1454.61, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 1454.61, "10th_percentile": 1454.61, "90th_percentile": 1454.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 909.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 909.13, "10th_percentile": 909.13, "90th_percentile": 909.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 296.38, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 296.38, "10th_percentile": 296.38, "90th_percentile": 296.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 1454.61, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 1454.61, "10th_percentile": 1454.61, "90th_percentile": 1454.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 1267.69, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1267.69, "10th_percentile": 1267.69, "90th_percentile": 1267.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 1254.6, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 1254.6, "10th_percentile": 1254.6, "90th_percentile": 1254.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 1234.6, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1234.6, "10th_percentile": 1234.6, "90th_percentile": 1234.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1818.26, "10th_percentile": 1818.26, "90th_percentile": 1818.26, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1818.26, "10th_percentile": 1818.26, "90th_percentile": 1818.26, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1818.26, "10th_percentile": 1818.26, "90th_percentile": 1818.26, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1818.26, "10th_percentile": 1818.26, "90th_percentile": 1818.26, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1818.26, "10th_percentile": 1818.26, "90th_percentile": 1818.26, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1818.26, "10th_percentile": 1818.26, "90th_percentile": 1818.26, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1818.26, "10th_percentile": 1818.26, "90th_percentile": 1818.26, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1818.26, "10th_percentile": 1818.26, "90th_percentile": 1818.26, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 1636.43, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 1636.43, "10th_percentile": 1636.43, "90th_percentile": 1636.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1818.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1818.26, "10th_percentile": 1818.26, "90th_percentile": 1818.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 1363.7, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 1363.7, "10th_percentile": 1363.7, "90th_percentile": 1363.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 1167.87, "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": 1167.87, "10th_percentile": 1167.87, "90th_percentile": 1167.87, "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": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 1145.5, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 1145.5, "10th_percentile": 1145.5, "90th_percentile": 1145.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1818.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1818.26, "10th_percentile": 1818.26, "90th_percentile": 1818.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 958.22, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 958.22, "10th_percentile": 958.22, "90th_percentile": 958.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 861.86, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 861.86, "10th_percentile": 861.86, "90th_percentile": 861.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 1818.26, "10th_percentile": 1818.26, "90th_percentile": 1818.26, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1818.26, "10th_percentile": 1818.26, "90th_percentile": 1818.26, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1818.26, "10th_percentile": 1818.26, "90th_percentile": 1818.26, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BIT DRILL 3.2MM STRL 321-52-07", "code_information": [ { "code": "SUP-344730", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 315.73, "maximum": 1936.98, "setting": "outpatient", "gross_charge": 1936.98, "discounted_cash": 1355.89, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 1743.28, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 1743.28, "10th_percentile": 1743.28, "90th_percentile": 1743.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1936.98, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1936.98, "10th_percentile": 1936.98, "90th_percentile": 1936.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 918.13, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 918.13, "10th_percentile": 918.13, "90th_percentile": 918.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 1020.79, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1020.79, "10th_percentile": 1020.79, "90th_percentile": 1020.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1936.98, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1936.98, "10th_percentile": 1936.98, "90th_percentile": 1936.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 1244.12, "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": 1244.12, "10th_percentile": 1244.12, "90th_percentile": 1244.12, "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": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 1452.74, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 1452.74, "10th_percentile": 1452.74, "90th_percentile": 1452.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 1936.98, "10th_percentile": 1936.98, "90th_percentile": 1936.98, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1936.98, "10th_percentile": 1936.98, "90th_percentile": 1936.98, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1936.98, "10th_percentile": 1936.98, "90th_percentile": 1936.98, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 547.78, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 547.78, "10th_percentile": 547.78, "90th_percentile": 547.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 542.35, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 542.35, "10th_percentile": 542.35, "90th_percentile": 542.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1082.77, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1082.77, "10th_percentile": 1082.77, "90th_percentile": 1082.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 698.09, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 698.09, "10th_percentile": 698.09, "90th_percentile": 698.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 1350.46, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1350.46, "10th_percentile": 1350.46, "90th_percentile": 1350.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 558.63, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 558.63, "10th_percentile": 558.63, "90th_percentile": 558.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 1743.28, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 1743.28, "10th_percentile": 1743.28, "90th_percentile": 1743.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 1315.21, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1315.21, "10th_percentile": 1315.21, "90th_percentile": 1315.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 968.49, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 968.49, "10th_percentile": 968.49, "90th_percentile": 968.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 1336.52, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 1336.52, "10th_percentile": 1336.52, "90th_percentile": 1336.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 1350.46, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1350.46, "10th_percentile": 1350.46, "90th_percentile": 1350.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH COMPSYCH", "standard_charge_dollar": 1549.58, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 1549.58, "10th_percentile": 1549.58, "90th_percentile": 1549.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 315.73, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 315.73, "10th_percentile": 315.73, "90th_percentile": 315.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 1220.3, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 1220.3, "10th_percentile": 1220.3, "90th_percentile": 1220.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 698.09, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 698.09, "10th_percentile": 698.09, "90th_percentile": 698.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 422.26, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 422.26, "10th_percentile": 422.26, "90th_percentile": 422.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 949.12, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 949.12, "10th_percentile": 949.12, "90th_percentile": 949.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1549.58, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 1549.58, "10th_percentile": 1549.58, "90th_percentile": 1549.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 1646.43, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 1646.43, "10th_percentile": 1646.43, "90th_percentile": 1646.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 968.49, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 968.49, "10th_percentile": 968.49, "90th_percentile": 968.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 1452.74, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 1452.74, "10th_percentile": 1452.74, "90th_percentile": 1452.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 1259.04, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 1259.04, "10th_percentile": 1259.04, "90th_percentile": 1259.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 1200.93, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1200.93, "10th_percentile": 1200.93, "90th_percentile": 1200.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 1200.93, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1200.93, "10th_percentile": 1200.93, "90th_percentile": 1200.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1936.98, "10th_percentile": 1936.98, "90th_percentile": 1936.98, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1936.98, "10th_percentile": 1936.98, "90th_percentile": 1936.98, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1936.98, "10th_percentile": 1936.98, "90th_percentile": 1936.98, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1936.98, "10th_percentile": 1936.98, "90th_percentile": 1936.98, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1936.98, "10th_percentile": 1936.98, "90th_percentile": 1936.98, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1936.98, "10th_percentile": 1936.98, "90th_percentile": 1936.98, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1936.98, "10th_percentile": 1936.98, "90th_percentile": 1936.98, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1936.98, "10th_percentile": 1936.98, "90th_percentile": 1936.98, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BIT DRILL 3.2X230MM WITHOUT STOP NONRADIOLUCENT 705232", "code_information": [ { "code": "SUP-331813", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 201.34, "maximum": 1235.21, "setting": "outpatient", "gross_charge": 1235.21, "discounted_cash": 864.65, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 356.23, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 356.23, "10th_percentile": 356.23, "90th_percentile": 356.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 345.86, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 345.86, "10th_percentile": 345.86, "90th_percentile": 345.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 445.17, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 445.17, "10th_percentile": 445.17, "90th_percentile": 445.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 690.48, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 690.48, "10th_percentile": 690.48, "90th_percentile": 690.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 349.32, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 861.19, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 861.19, "10th_percentile": 861.19, "90th_percentile": 861.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 765.83, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 765.83, "10th_percentile": 765.83, "90th_percentile": 765.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 765.83, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 765.83, "10th_percentile": 765.83, "90th_percentile": 765.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 1111.69, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 1111.69, "10th_percentile": 1111.69, "90th_percentile": 1111.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 1111.69, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 1111.69, "10th_percentile": 1111.69, "90th_percentile": 1111.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 617.61, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 617.61, "10th_percentile": 617.61, "90th_percentile": 617.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 802.89, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 802.89, "10th_percentile": 802.89, "90th_percentile": 802.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 926.41, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 926.41, "10th_percentile": 926.41, "90th_percentile": 926.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 1049.93, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 1049.93, "10th_percentile": 1049.93, "90th_percentile": 1049.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 445.17, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 445.17, "10th_percentile": 445.17, "90th_percentile": 445.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 585.49, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 585.49, "10th_percentile": 585.49, "90th_percentile": 585.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1235.21, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1235.21, "10th_percentile": 1235.21, "90th_percentile": 1235.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 650.96, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 650.96, "10th_percentile": 650.96, "90th_percentile": 650.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 778.18, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 778.18, "10th_percentile": 778.18, "90th_percentile": 778.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 269.28, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 269.28, "10th_percentile": 269.28, "90th_percentile": 269.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 605.25, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 605.25, "10th_percentile": 605.25, "90th_percentile": 605.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 988.17, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 988.17, "10th_percentile": 988.17, "90th_percentile": 988.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 617.61, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 617.61, "10th_percentile": 617.61, "90th_percentile": 617.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 201.34, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 201.34, "10th_percentile": 201.34, "90th_percentile": 201.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 988.17, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 988.17, "10th_percentile": 988.17, "90th_percentile": 988.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 793.38, "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": 793.38, "10th_percentile": 793.38, "90th_percentile": 793.38, "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": "DCH PHCS", "standard_charge_dollar": 926.41, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 926.41, "10th_percentile": 926.41, "90th_percentile": 926.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 861.19, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 861.19, "10th_percentile": 861.19, "90th_percentile": 861.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 852.29, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 852.29, "10th_percentile": 852.29, "90th_percentile": 852.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 838.71, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 838.71, "10th_percentile": 838.71, "90th_percentile": 838.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1235.21, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1235.21, "10th_percentile": 1235.21, "90th_percentile": 1235.21, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 1235.21, "10th_percentile": 1235.21, "90th_percentile": 1235.21, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1235.21, "10th_percentile": 1235.21, "90th_percentile": 1235.21, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1235.21, "10th_percentile": 1235.21, "90th_percentile": 1235.21, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1235.21, "10th_percentile": 1235.21, "90th_percentile": 1235.21, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1235.21, "10th_percentile": 1235.21, "90th_percentile": 1235.21, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1235.21, "10th_percentile": 1235.21, "90th_percentile": 1235.21, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1235.21, "10th_percentile": 1235.21, "90th_percentile": 1235.21, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1235.21, "10th_percentile": 1235.21, "90th_percentile": 1235.21, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1235.21, "10th_percentile": 1235.21, "90th_percentile": 1235.21, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1235.21, "10th_percentile": 1235.21, "90th_percentile": 1235.21, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1235.21, "10th_percentile": 1235.21, "90th_percentile": 1235.21, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BIT DRILL 4.5/6.5MM 485MM TI STEPPED RECON 03.010.078", "code_information": [ { "code": "SUP-344359", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 547.22, "maximum": 3357.19, "setting": "outpatient", "gross_charge": 3357.19, "discounted_cash": 2350.03, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 2081.46, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2081.46, "10th_percentile": 2081.46, "90th_percentile": 2081.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 2081.46, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2081.46, "10th_percentile": 2081.46, "90th_percentile": 2081.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 968.21, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 968.21, "10th_percentile": 968.21, "90th_percentile": 968.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 2340.63, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2340.63, "10th_percentile": 2340.63, "90th_percentile": 2340.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 949.41, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 949.41, "10th_percentile": 949.41, "90th_percentile": 949.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1876.67, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1876.67, "10th_percentile": 1876.67, "90th_percentile": 1876.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 1209.93, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1209.93, "10th_percentile": 1209.93, "90th_percentile": 1209.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 940.01, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 940.01, "10th_percentile": 940.01, "90th_percentile": 940.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 3021.47, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 3021.47, "10th_percentile": 3021.47, "90th_percentile": 3021.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 3021.47, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 3021.47, "10th_percentile": 3021.47, "90th_percentile": 3021.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 1678.6, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 1678.6, "10th_percentile": 1678.6, "90th_percentile": 1678.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 2182.17, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 2182.17, "10th_percentile": 2182.17, "90th_percentile": 2182.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 2517.89, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 2517.89, "10th_percentile": 2517.89, "90th_percentile": 2517.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 2853.61, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 2853.61, "10th_percentile": 2853.61, "90th_percentile": 2853.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 2279.53, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2279.53, "10th_percentile": 2279.53, "90th_percentile": 2279.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3357.19, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3357.19, "10th_percentile": 3357.19, "90th_percentile": 3357.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 2685.75, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 2685.75, "10th_percentile": 2685.75, "90th_percentile": 2685.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 1591.31, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1591.31, "10th_percentile": 1591.31, "90th_percentile": 1591.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 1769.24, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1769.24, "10th_percentile": 1769.24, "90th_percentile": 1769.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 3357.19, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 3357.19, "10th_percentile": 3357.19, "90th_percentile": 3357.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 2156.32, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 2156.32, "10th_percentile": 2156.32, "90th_percentile": 2156.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 2517.89, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 2517.89, "10th_percentile": 2517.89, "90th_percentile": 2517.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 731.87, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 731.87, "10th_percentile": 731.87, "90th_percentile": 731.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 2685.75, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 2685.75, "10th_percentile": 2685.75, "90th_percentile": 2685.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 1645.02, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1645.02, "10th_percentile": 1645.02, "90th_percentile": 1645.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 1678.6, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1678.6, "10th_percentile": 1678.6, "90th_percentile": 1678.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 2340.63, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2340.63, "10th_percentile": 2340.63, "90th_percentile": 2340.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 2316.46, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 2316.46, "10th_percentile": 2316.46, "90th_percentile": 2316.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 547.22, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 547.22, "10th_percentile": 547.22, "90th_percentile": 547.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 1209.93, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1209.93, "10th_percentile": 1209.93, "90th_percentile": 1209.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 2115.03, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 2115.03, "10th_percentile": 2115.03, "90th_percentile": 2115.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 3357.19, "10th_percentile": 3357.19, "90th_percentile": 3357.19, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3357.19, "10th_percentile": 3357.19, "90th_percentile": 3357.19, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3357.19, "10th_percentile": 3357.19, "90th_percentile": 3357.19, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3357.19, "10th_percentile": 3357.19, "90th_percentile": 3357.19, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3357.19, "10th_percentile": 3357.19, "90th_percentile": 3357.19, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3357.19, "10th_percentile": 3357.19, "90th_percentile": 3357.19, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3357.19, "10th_percentile": 3357.19, "90th_percentile": 3357.19, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3357.19, "10th_percentile": 3357.19, "90th_percentile": 3357.19, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3357.19, "10th_percentile": 3357.19, "90th_percentile": 3357.19, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3357.19, "10th_percentile": 3357.19, "90th_percentile": 3357.19, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3357.19, "10th_percentile": 3357.19, "90th_percentile": 3357.19, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BIT DRILL OD1.7MM FLEXIBLE DISPOSABLE FIBERTAK AR-3600ND-3", "code_information": [ { "code": "SUP-416696", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 174.23, "maximum": 1068.88, "setting": "outpatient", "gross_charge": 1068.88, "discounted_cash": 748.22, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 308.26, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 308.26, "10th_percentile": 308.26, "90th_percentile": 308.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 299.29, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 299.29, "10th_percentile": 299.29, "90th_percentile": 299.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 302.28, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 302.28, "10th_percentile": 302.28, "90th_percentile": 302.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 745.22, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 745.22, "10th_percentile": 745.22, "90th_percentile": 745.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 662.71, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 662.71, "10th_percentile": 662.71, "90th_percentile": 662.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 961.99, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 961.99, "10th_percentile": 961.99, "90th_percentile": 961.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 385.22, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 385.22, "10th_percentile": 385.22, "90th_percentile": 385.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 174.23, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 174.23, "10th_percentile": 174.23, "90th_percentile": 174.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 745.22, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 745.22, "10th_percentile": 745.22, "90th_percentile": 745.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 725.77, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 725.77, "10th_percentile": 725.77, "90th_percentile": 725.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1068.88, "10th_percentile": 1068.88, "90th_percentile": 1068.88, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1068.88, "10th_percentile": 1068.88, "90th_percentile": 1068.88, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1068.88, "10th_percentile": 1068.88, "90th_percentile": 1068.88, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1068.88, "10th_percentile": 1068.88, "90th_percentile": 1068.88, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 597.5, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 597.5, "10th_percentile": 597.5, "90th_percentile": 597.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 385.22, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 385.22, "10th_percentile": 385.22, "90th_percentile": 385.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 961.99, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 961.99, "10th_percentile": 961.99, "90th_percentile": 961.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1068.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1068.88, "10th_percentile": 1068.88, "90th_percentile": 1068.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 801.66, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 801.66, "10th_percentile": 801.66, "90th_percentile": 801.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 686.54, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 686.54, "10th_percentile": 686.54, "90th_percentile": 686.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 534.44, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 534.44, "10th_percentile": 534.44, "90th_percentile": 534.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 737.53, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 737.53, "10th_percentile": 737.53, "90th_percentile": 737.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 855.1, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 855.1, "10th_percentile": 855.1, "90th_percentile": 855.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 673.39, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 673.39, "10th_percentile": 673.39, "90th_percentile": 673.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 233.02, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 233.02, "10th_percentile": 233.02, "90th_percentile": 233.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 523.75, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 523.75, "10th_percentile": 523.75, "90th_percentile": 523.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 855.1, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 855.1, "10th_percentile": 855.1, "90th_percentile": 855.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1068.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1068.88, "10th_percentile": 1068.88, "90th_percentile": 1068.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 563.3, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 563.3, "10th_percentile": 563.3, "90th_percentile": 563.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 506.65, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 506.65, "10th_percentile": 506.65, "90th_percentile": 506.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 908.55, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 908.55, "10th_percentile": 908.55, "90th_percentile": 908.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 534.44, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 534.44, "10th_percentile": 534.44, "90th_percentile": 534.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 801.66, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 801.66, "10th_percentile": 801.66, "90th_percentile": 801.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 694.77, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 694.77, "10th_percentile": 694.77, "90th_percentile": 694.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 662.71, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 662.71, "10th_percentile": 662.71, "90th_percentile": 662.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 1068.88, "10th_percentile": 1068.88, "90th_percentile": 1068.88, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1068.88, "10th_percentile": 1068.88, "90th_percentile": 1068.88, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1068.88, "10th_percentile": 1068.88, "90th_percentile": 1068.88, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1068.88, "10th_percentile": 1068.88, "90th_percentile": 1068.88, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1068.88, "10th_percentile": 1068.88, "90th_percentile": 1068.88, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1068.88, "10th_percentile": 1068.88, "90th_percentile": 1068.88, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1068.88, "10th_percentile": 1068.88, "90th_percentile": 1068.88, "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": 46.85, "maximum": 287.44, "setting": "outpatient", "gross_charge": 287.44, "discounted_cash": 201.21, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 81.29, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 81.29, "10th_percentile": 81.29, "90th_percentile": 81.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 80.48, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 80.48, "10th_percentile": 80.48, "90th_percentile": 80.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 160.68, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 160.68, "10th_percentile": 160.68, "90th_percentile": 160.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 103.59, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 103.59, "10th_percentile": 103.59, "90th_percentile": 103.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 200.4, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 200.4, "10th_percentile": 200.4, "90th_percentile": 200.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 82.9, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 82.9, "10th_percentile": 82.9, "90th_percentile": 82.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 258.7, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 258.7, "10th_percentile": 258.7, "90th_percentile": 258.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 258.7, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 258.7, "10th_percentile": 258.7, "90th_percentile": 258.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 287.44, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 287.44, "10th_percentile": 287.44, "90th_percentile": 287.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 215.58, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 215.58, "10th_percentile": 215.58, "90th_percentile": 215.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 195.17, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 195.17, "10th_percentile": 195.17, "90th_percentile": 195.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH THE ALLIANCE", "standard_charge_dollar": 184.62, "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": 184.62, "10th_percentile": 184.62, "90th_percentile": 184.62, "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": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 143.72, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 143.72, "10th_percentile": 143.72, "90th_percentile": 143.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 198.33, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 198.33, "10th_percentile": 198.33, "90th_percentile": 198.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 200.4, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 200.4, "10th_percentile": 200.4, "90th_percentile": 200.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH COMPSYCH", "standard_charge_dollar": 229.95, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 229.95, "10th_percentile": 229.95, "90th_percentile": 229.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 46.85, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 46.85, "10th_percentile": 46.85, "90th_percentile": 46.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 181.09, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 181.09, "10th_percentile": 181.09, "90th_percentile": 181.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 103.59, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 103.59, "10th_percentile": 103.59, "90th_percentile": 103.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 62.66, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 62.66, "10th_percentile": 62.66, "90th_percentile": 62.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 140.85, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 140.85, "10th_percentile": 140.85, "90th_percentile": 140.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 229.95, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 229.95, "10th_percentile": 229.95, "90th_percentile": 229.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 287.44, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 287.44, "10th_percentile": 287.44, "90th_percentile": 287.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 151.48, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 151.48, "10th_percentile": 151.48, "90th_percentile": 151.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 136.25, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 136.25, "10th_percentile": 136.25, "90th_percentile": 136.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 244.32, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 244.32, "10th_percentile": 244.32, "90th_percentile": 244.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 143.72, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 143.72, "10th_percentile": 143.72, "90th_percentile": 143.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 215.58, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 215.58, "10th_percentile": 215.58, "90th_percentile": 215.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 186.84, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 186.84, "10th_percentile": 186.84, "90th_percentile": 186.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 178.21, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 178.21, "10th_percentile": 178.21, "90th_percentile": 178.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 178.21, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 178.21, "10th_percentile": 178.21, "90th_percentile": 178.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 287.44, "10th_percentile": 287.44, "90th_percentile": 287.44, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 287.44, "10th_percentile": 287.44, "90th_percentile": 287.44, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 287.44, "10th_percentile": 287.44, "90th_percentile": 287.44, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 287.44, "10th_percentile": 287.44, "90th_percentile": 287.44, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 287.44, "10th_percentile": 287.44, "90th_percentile": 287.44, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 287.44, "10th_percentile": 287.44, "90th_percentile": 287.44, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 287.44, "10th_percentile": 287.44, "90th_percentile": 287.44, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 287.44, "10th_percentile": 287.44, "90th_percentile": 287.44, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 287.44, "10th_percentile": 287.44, "90th_percentile": 287.44, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 287.44, "10th_percentile": 287.44, "90th_percentile": 287.44, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 287.44, "10th_percentile": 287.44, "90th_percentile": 287.44, "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": 244.72, "maximum": 1501.33, "setting": "outpatient", "gross_charge": 1501.33, "discounted_cash": 1050.93, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 432.98, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 432.98, "10th_percentile": 432.98, "90th_percentile": 432.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 420.37, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 420.37, "10th_percentile": 420.37, "90th_percentile": 420.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 541.08, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 541.08, "10th_percentile": 541.08, "90th_percentile": 541.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 839.24, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 839.24, "10th_percentile": 839.24, "90th_percentile": 839.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 424.58, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 424.58, "10th_percentile": 424.58, "90th_percentile": 424.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 1046.73, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1046.73, "10th_percentile": 1046.73, "90th_percentile": 1046.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 930.82, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 930.82, "10th_percentile": 930.82, "90th_percentile": 930.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 930.82, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 930.82, "10th_percentile": 930.82, "90th_percentile": 930.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 1351.2, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 1351.2, "10th_percentile": 1351.2, "90th_percentile": 1351.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 1351.2, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 1351.2, "10th_percentile": 1351.2, "90th_percentile": 1351.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 750.67, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 750.67, "10th_percentile": 750.67, "90th_percentile": 750.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 975.86, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 975.86, "10th_percentile": 975.86, "90th_percentile": 975.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 1126.0, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 1126.0, "10th_percentile": 1126.0, "90th_percentile": 1126.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 1276.13, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 1276.13, "10th_percentile": 1276.13, "90th_percentile": 1276.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 541.08, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 541.08, "10th_percentile": 541.08, "90th_percentile": 541.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 711.63, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 711.63, "10th_percentile": 711.63, "90th_percentile": 711.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1501.33, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1501.33, "10th_percentile": 1501.33, "90th_percentile": 1501.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 791.2, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 791.2, "10th_percentile": 791.2, "90th_percentile": 791.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 945.84, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 945.84, "10th_percentile": 945.84, "90th_percentile": 945.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 327.29, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 327.29, "10th_percentile": 327.29, "90th_percentile": 327.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 735.65, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 735.65, "10th_percentile": 735.65, "90th_percentile": 735.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1201.06, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 1201.06, "10th_percentile": 1201.06, "90th_percentile": 1201.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 750.67, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 750.67, "10th_percentile": 750.67, "90th_percentile": 750.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 244.72, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 244.72, "10th_percentile": 244.72, "90th_percentile": 244.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 1201.06, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 1201.06, "10th_percentile": 1201.06, "90th_percentile": 1201.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 964.3, "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": 964.3, "10th_percentile": 964.3, "90th_percentile": 964.3, "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": "DCH PHCS", "standard_charge_dollar": 1126.0, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 1126.0, "10th_percentile": 1126.0, "90th_percentile": 1126.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 1046.73, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1046.73, "10th_percentile": 1046.73, "90th_percentile": 1046.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 1035.92, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 1035.92, "10th_percentile": 1035.92, "90th_percentile": 1035.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 1019.4, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1019.4, "10th_percentile": 1019.4, "90th_percentile": 1019.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1501.33, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1501.33, "10th_percentile": 1501.33, "90th_percentile": 1501.33, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 1501.33, "10th_percentile": 1501.33, "90th_percentile": 1501.33, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1501.33, "10th_percentile": 1501.33, "90th_percentile": 1501.33, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1501.33, "10th_percentile": 1501.33, "90th_percentile": 1501.33, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1501.33, "10th_percentile": 1501.33, "90th_percentile": 1501.33, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1501.33, "10th_percentile": 1501.33, "90th_percentile": 1501.33, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1501.33, "10th_percentile": 1501.33, "90th_percentile": 1501.33, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1501.33, "10th_percentile": 1501.33, "90th_percentile": 1501.33, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1501.33, "10th_percentile": 1501.33, "90th_percentile": 1501.33, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1501.33, "10th_percentile": 1501.33, "90th_percentile": 1501.33, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1501.33, "10th_percentile": 1501.33, "90th_percentile": 1501.33, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1501.33, "10th_percentile": 1501.33, "90th_percentile": 1501.33, "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": 664.47, "maximum": 4076.48, "setting": "outpatient", "gross_charge": 4076.48, "discounted_cash": 2853.54, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 2527.42, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2527.42, "10th_percentile": 2527.42, "90th_percentile": 2527.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 2767.93, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2767.93, "10th_percentile": 2767.93, "90th_percentile": 2767.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 2842.12, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2842.12, "10th_percentile": 2842.12, "90th_percentile": 2842.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 664.47, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 664.47, "10th_percentile": 664.47, "90th_percentile": 664.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 1469.16, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1469.16, "10th_percentile": 1469.16, "90th_percentile": 1469.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4076.48, "10th_percentile": 4076.48, "90th_percentile": 4076.48, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4076.48, "10th_percentile": 4076.48, "90th_percentile": 4076.48, "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": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1175.66, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1175.66, "10th_percentile": 1175.66, "90th_percentile": 1175.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1141.41, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1141.41, "10th_percentile": 1141.41, "90th_percentile": 1141.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 1469.16, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1469.16, "10th_percentile": 1469.16, "90th_percentile": 1469.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2278.75, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2278.75, "10th_percentile": 2278.75, "90th_percentile": 2278.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1152.83, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1152.83, "10th_percentile": 1152.83, "90th_percentile": 1152.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 2842.12, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2842.12, "10th_percentile": 2842.12, "90th_percentile": 2842.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 2527.42, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2527.42, "10th_percentile": 2527.42, "90th_percentile": 2527.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 3668.83, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 3668.83, "10th_percentile": 3668.83, "90th_percentile": 3668.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 3668.83, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 3668.83, "10th_percentile": 3668.83, "90th_percentile": 3668.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 2038.24, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 2038.24, "10th_percentile": 2038.24, "90th_percentile": 2038.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 2649.71, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 2649.71, "10th_percentile": 2649.71, "90th_percentile": 2649.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 3057.36, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 3057.36, "10th_percentile": 3057.36, "90th_percentile": 3057.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 3465.01, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 3465.01, "10th_percentile": 3465.01, "90th_percentile": 3465.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 1932.25, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1932.25, "10th_percentile": 1932.25, "90th_percentile": 1932.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 4076.48, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 4076.48, "10th_percentile": 4076.48, "90th_percentile": 4076.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 2148.3, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2148.3, "10th_percentile": 2148.3, "90th_percentile": 2148.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 2568.18, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 2568.18, "10th_percentile": 2568.18, "90th_percentile": 2568.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 888.67, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 888.67, "10th_percentile": 888.67, "90th_percentile": 888.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 1997.48, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1997.48, "10th_percentile": 1997.48, "90th_percentile": 1997.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 3261.18, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 3261.18, "10th_percentile": 3261.18, "90th_percentile": 3261.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 2038.24, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2038.24, "10th_percentile": 2038.24, "90th_percentile": 2038.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 3261.18, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 3261.18, "10th_percentile": 3261.18, "90th_percentile": 3261.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 2618.32, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 2618.32, "10th_percentile": 2618.32, "90th_percentile": 2618.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 3057.36, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 3057.36, "10th_percentile": 3057.36, "90th_percentile": 3057.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 2812.77, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 2812.77, "10th_percentile": 2812.77, "90th_percentile": 2812.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4076.48, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4076.48, "10th_percentile": 4076.48, "90th_percentile": 4076.48, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 4076.48, "10th_percentile": 4076.48, "90th_percentile": 4076.48, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4076.48, "10th_percentile": 4076.48, "90th_percentile": 4076.48, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4076.48, "10th_percentile": 4076.48, "90th_percentile": 4076.48, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4076.48, "10th_percentile": 4076.48, "90th_percentile": 4076.48, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4076.48, "10th_percentile": 4076.48, "90th_percentile": 4076.48, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4076.48, "10th_percentile": 4076.48, "90th_percentile": 4076.48, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4076.48, "10th_percentile": 4076.48, "90th_percentile": 4076.48, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4076.48, "10th_percentile": 4076.48, "90th_percentile": 4076.48, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4076.48, "10th_percentile": 4076.48, "90th_percentile": 4076.48, "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": 53.53, "maximum": 359.25, "setting": "outpatient", "gross_charge": 359.25, "discounted_cash": 251.47, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 359.25, "10th_percentile": 359.25, "90th_percentile": 359.25, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 359.25, "10th_percentile": 359.25, "90th_percentile": 359.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 359.25, "10th_percentile": 359.25, "90th_percentile": 359.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 359.25, "10th_percentile": 359.25, "90th_percentile": 359.25, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 359.25, "10th_percentile": 359.25, "90th_percentile": 359.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 359.25, "10th_percentile": 359.25, "90th_percentile": 359.25, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 359.25, "10th_percentile": 359.25, "90th_percentile": 359.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $359.25 @ 6.8% = $24.43 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": 24.43, "10th_percentile": 24.43, "90th_percentile": 24.43, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $359.25 @ 6.8% = $24.43 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": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $359.25 @ 6.8% = $24.43 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": 24.43, "10th_percentile": 24.43, "90th_percentile": 24.43, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $359.25 @ 6.8% = $24.43 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $359.25 @ 6.8% = $24.43 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": 24.43, "10th_percentile": 24.43, "90th_percentile": 24.43, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $359.25 @ 6.8% = $24.43 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": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $359.25 @ 12.5% = $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 - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $359.25 @ 12.5% = $44.91 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 64.67, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 64.67, "10th_percentile": 64.67, "90th_percentile": 64.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 58.56, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 58.56, "10th_percentile": 58.56, "90th_percentile": 58.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 200.82, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 200.82, "10th_percentile": 200.82, "90th_percentile": 200.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 179.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 179.63, "10th_percentile": 179.63, "90th_percentile": 179.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 269.44, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 269.44, "10th_percentile": 269.44, "90th_percentile": 269.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 359.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 359.25, "10th_percentile": 359.25, "90th_percentile": 359.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 247.88, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 247.88, "10th_percentile": 247.88, "90th_percentile": 247.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 287.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 287.4, "10th_percentile": 287.4, "90th_percentile": 287.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 287.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 287.4, "10th_percentile": 287.4, "90th_percentile": 287.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 359.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 359.25, "10th_percentile": 359.25, "90th_percentile": 359.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 226.33, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 226.33, "10th_percentile": 226.33, "90th_percentile": 226.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 305.36, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 305.36, "10th_percentile": 305.36, "90th_percentile": 305.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 179.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 179.63, "10th_percentile": 179.63, "90th_percentile": 179.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 269.44, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 269.44, "10th_percentile": 269.44, "90th_percentile": 269.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 233.51, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 233.51, "10th_percentile": 233.51, "90th_percentile": 233.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 53.53, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 53.53, "10th_percentile": 53.53, "90th_percentile": 53.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 53.53, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 53.53, "10th_percentile": 53.53, "90th_percentile": 53.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 323.33, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 323.33, "10th_percentile": 323.33, "90th_percentile": 323.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 323.33, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 323.33, "10th_percentile": 323.33, "90th_percentile": 323.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 83.71, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 83.71, "10th_percentile": 83.71, "90th_percentile": 83.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 83.71, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 83.71, "10th_percentile": 83.71, "90th_percentile": 83.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 250.47, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 250.47, "10th_percentile": 250.47, "90th_percentile": 250.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 250.47, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 250.47, "10th_percentile": 250.47, "90th_percentile": 250.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "BLADE GLIDESCOPE TITANIUM SPECTRUM LOPRO S3 0270-0938", "code_information": [ { "code": "SUP-341029", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 62.07, "maximum": 380.79, "setting": "outpatient", "gross_charge": 380.79, "discounted_cash": 266.55, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 236.09, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 236.09, "10th_percentile": 236.09, "90th_percentile": 236.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 236.09, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 236.09, "10th_percentile": 236.09, "90th_percentile": 236.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 109.82, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 109.82, "10th_percentile": 109.82, "90th_percentile": 109.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 265.49, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 265.49, "10th_percentile": 265.49, "90th_percentile": 265.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 107.69, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 107.69, "10th_percentile": 107.69, "90th_percentile": 107.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 212.86, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 212.86, "10th_percentile": 212.86, "90th_percentile": 212.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 137.24, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 137.24, "10th_percentile": 137.24, "90th_percentile": 137.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 106.62, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 106.62, "10th_percentile": 106.62, "90th_percentile": 106.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 342.71, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 342.71, "10th_percentile": 342.71, "90th_percentile": 342.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 342.71, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 342.71, "10th_percentile": 342.71, "90th_percentile": 342.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 190.4, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 190.4, "10th_percentile": 190.4, "90th_percentile": 190.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 247.51, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 247.51, "10th_percentile": 247.51, "90th_percentile": 247.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 285.59, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 285.59, "10th_percentile": 285.59, "90th_percentile": 285.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 323.67, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 323.67, "10th_percentile": 323.67, "90th_percentile": 323.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 258.56, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 258.56, "10th_percentile": 258.56, "90th_percentile": 258.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 380.79, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 380.79, "10th_percentile": 380.79, "90th_percentile": 380.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 304.63, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 304.63, "10th_percentile": 304.63, "90th_percentile": 304.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 180.49, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 180.49, "10th_percentile": 180.49, "90th_percentile": 180.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 200.68, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 200.68, "10th_percentile": 200.68, "90th_percentile": 200.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 380.79, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 380.79, "10th_percentile": 380.79, "90th_percentile": 380.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 244.58, "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": 244.58, "10th_percentile": 244.58, "90th_percentile": 244.58, "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": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 285.59, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 285.59, "10th_percentile": 285.59, "90th_percentile": 285.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 83.01, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 83.01, "10th_percentile": 83.01, "90th_percentile": 83.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 304.63, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 304.63, "10th_percentile": 304.63, "90th_percentile": 304.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 186.59, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 186.59, "10th_percentile": 186.59, "90th_percentile": 186.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 190.4, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 190.4, "10th_percentile": 190.4, "90th_percentile": 190.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 265.49, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 265.49, "10th_percentile": 265.49, "90th_percentile": 265.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 262.75, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 262.75, "10th_percentile": 262.75, "90th_percentile": 262.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 62.07, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 62.07, "10th_percentile": 62.07, "90th_percentile": 62.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 137.24, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 137.24, "10th_percentile": 137.24, "90th_percentile": 137.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 239.9, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 239.9, "10th_percentile": 239.9, "90th_percentile": 239.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 380.79, "10th_percentile": 380.79, "90th_percentile": 380.79, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 380.79, "10th_percentile": 380.79, "90th_percentile": 380.79, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 380.79, "10th_percentile": 380.79, "90th_percentile": 380.79, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 380.79, "10th_percentile": 380.79, "90th_percentile": 380.79, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 380.79, "10th_percentile": 380.79, "90th_percentile": 380.79, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 380.79, "10th_percentile": 380.79, "90th_percentile": 380.79, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 380.79, "10th_percentile": 380.79, "90th_percentile": 380.79, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 380.79, "10th_percentile": 380.79, "90th_percentile": 380.79, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 380.79, "10th_percentile": 380.79, "90th_percentile": 380.79, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 380.79, "10th_percentile": 380.79, "90th_percentile": 380.79, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 380.79, "10th_percentile": 380.79, "90th_percentile": 380.79, "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": 608.34, "maximum": 3732.12, "setting": "outpatient", "gross_charge": 3732.12, "discounted_cash": 2612.48, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1076.34, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1076.34, "10th_percentile": 1076.34, "90th_percentile": 1076.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1044.99, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1044.99, "10th_percentile": 1044.99, "90th_percentile": 1044.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 1345.06, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1345.06, "10th_percentile": 1345.06, "90th_percentile": 1345.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2086.26, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2086.26, "10th_percentile": 2086.26, "90th_percentile": 2086.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1055.44, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1055.44, "10th_percentile": 1055.44, "90th_percentile": 1055.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 2602.03, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2602.03, "10th_percentile": 2602.03, "90th_percentile": 2602.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 2313.91, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2313.91, "10th_percentile": 2313.91, "90th_percentile": 2313.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 2313.91, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2313.91, "10th_percentile": 2313.91, "90th_percentile": 2313.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 3358.91, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 3358.91, "10th_percentile": 3358.91, "90th_percentile": 3358.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 3358.91, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 3358.91, "10th_percentile": 3358.91, "90th_percentile": 3358.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 1866.06, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 1866.06, "10th_percentile": 1866.06, "90th_percentile": 1866.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 2425.88, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 2425.88, "10th_percentile": 2425.88, "90th_percentile": 2425.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 2799.09, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 2799.09, "10th_percentile": 2799.09, "90th_percentile": 2799.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 3172.3, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 3172.3, "10th_percentile": 3172.3, "90th_percentile": 3172.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 1345.06, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1345.06, "10th_percentile": 1345.06, "90th_percentile": 1345.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 1769.02, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1769.02, "10th_percentile": 1769.02, "90th_percentile": 1769.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 3732.12, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 3732.12, "10th_percentile": 3732.12, "90th_percentile": 3732.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 1966.83, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1966.83, "10th_percentile": 1966.83, "90th_percentile": 1966.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 2351.24, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 2351.24, "10th_percentile": 2351.24, "90th_percentile": 2351.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 813.6, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 813.6, "10th_percentile": 813.6, "90th_percentile": 813.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 1828.74, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1828.74, "10th_percentile": 1828.74, "90th_percentile": 1828.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 2985.7, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 2985.7, "10th_percentile": 2985.7, "90th_percentile": 2985.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 1866.06, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1866.06, "10th_percentile": 1866.06, "90th_percentile": 1866.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 608.34, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 608.34, "10th_percentile": 608.34, "90th_percentile": 608.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 2985.7, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 2985.7, "10th_percentile": 2985.7, "90th_percentile": 2985.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 2397.14, "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": 2397.14, "10th_percentile": 2397.14, "90th_percentile": 2397.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 2799.09, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 2799.09, "10th_percentile": 2799.09, "90th_percentile": 2799.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 2602.03, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2602.03, "10th_percentile": 2602.03, "90th_percentile": 2602.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 2575.16, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 2575.16, "10th_percentile": 2575.16, "90th_percentile": 2575.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 2534.11, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2534.11, "10th_percentile": 2534.11, "90th_percentile": 2534.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3732.12, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3732.12, "10th_percentile": 3732.12, "90th_percentile": 3732.12, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 3732.12, "10th_percentile": 3732.12, "90th_percentile": 3732.12, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3732.12, "10th_percentile": 3732.12, "90th_percentile": 3732.12, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3732.12, "10th_percentile": 3732.12, "90th_percentile": 3732.12, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3732.12, "10th_percentile": 3732.12, "90th_percentile": 3732.12, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3732.12, "10th_percentile": 3732.12, "90th_percentile": 3732.12, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3732.12, "10th_percentile": 3732.12, "90th_percentile": 3732.12, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3732.12, "10th_percentile": 3732.12, "90th_percentile": 3732.12, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3732.12, "10th_percentile": 3732.12, "90th_percentile": 3732.12, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3732.12, "10th_percentile": 3732.12, "90th_percentile": 3732.12, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3732.12, "10th_percentile": 3732.12, "90th_percentile": 3732.12, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3732.12, "10th_percentile": 3732.12, "90th_percentile": 3732.12, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BLADE RADENOID PEDIATRIC ENT 40DEG 4MM 1884008", "code_information": [ { "code": "SUP-310356", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 274.62, "maximum": 1684.81, "setting": "outpatient", "gross_charge": 1684.81, "discounted_cash": 1179.37, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 476.46, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 476.46, "10th_percentile": 476.46, "90th_percentile": 476.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 471.75, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 471.75, "10th_percentile": 471.75, "90th_percentile": 471.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 941.81, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 941.81, "10th_percentile": 941.81, "90th_percentile": 941.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 607.21, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 607.21, "10th_percentile": 607.21, "90th_percentile": 607.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 1174.65, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1174.65, "10th_percentile": 1174.65, "90th_percentile": 1174.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 485.9, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 485.9, "10th_percentile": 485.9, "90th_percentile": 485.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 1516.33, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 1516.33, "10th_percentile": 1516.33, "90th_percentile": 1516.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 1516.33, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 1516.33, "10th_percentile": 1516.33, "90th_percentile": 1516.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1684.81, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1684.81, "10th_percentile": 1684.81, "90th_percentile": 1684.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 1263.61, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 1263.61, "10th_percentile": 1263.61, "90th_percentile": 1263.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 1143.99, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1143.99, "10th_percentile": 1143.99, "90th_percentile": 1143.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH THE ALLIANCE", "standard_charge_dollar": 1082.15, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1082.15, "10th_percentile": 1082.15, "90th_percentile": 1082.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 842.41, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 842.41, "10th_percentile": 842.41, "90th_percentile": 842.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 1162.52, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 1162.52, "10th_percentile": 1162.52, "90th_percentile": 1162.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 1174.65, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1174.65, "10th_percentile": 1174.65, "90th_percentile": 1174.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH COMPSYCH", "standard_charge_dollar": 1347.85, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 1347.85, "10th_percentile": 1347.85, "90th_percentile": 1347.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 274.62, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 274.62, "10th_percentile": 274.62, "90th_percentile": 274.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 1061.43, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 1061.43, "10th_percentile": 1061.43, "90th_percentile": 1061.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 607.21, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 607.21, "10th_percentile": 607.21, "90th_percentile": 607.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 367.29, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 367.29, "10th_percentile": 367.29, "90th_percentile": 367.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 825.56, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 825.56, "10th_percentile": 825.56, "90th_percentile": 825.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1347.85, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 1347.85, "10th_percentile": 1347.85, "90th_percentile": 1347.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1684.81, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1684.81, "10th_percentile": 1684.81, "90th_percentile": 1684.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 887.89, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 887.89, "10th_percentile": 887.89, "90th_percentile": 887.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 798.6, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 798.6, "10th_percentile": 798.6, "90th_percentile": 798.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 1432.09, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 1432.09, "10th_percentile": 1432.09, "90th_percentile": 1432.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 842.41, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 842.41, "10th_percentile": 842.41, "90th_percentile": 842.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 1263.61, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 1263.61, "10th_percentile": 1263.61, "90th_percentile": 1263.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 1095.13, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 1095.13, "10th_percentile": 1095.13, "90th_percentile": 1095.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 1044.58, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1044.58, "10th_percentile": 1044.58, "90th_percentile": 1044.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 1044.58, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1044.58, "10th_percentile": 1044.58, "90th_percentile": 1044.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 1684.81, "10th_percentile": 1684.81, "90th_percentile": 1684.81, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1684.81, "10th_percentile": 1684.81, "90th_percentile": 1684.81, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1684.81, "10th_percentile": 1684.81, "90th_percentile": 1684.81, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1684.81, "10th_percentile": 1684.81, "90th_percentile": 1684.81, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1684.81, "10th_percentile": 1684.81, "90th_percentile": 1684.81, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1684.81, "10th_percentile": 1684.81, "90th_percentile": 1684.81, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1684.81, "10th_percentile": 1684.81, "90th_percentile": 1684.81, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1684.81, "10th_percentile": 1684.81, "90th_percentile": 1684.81, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1684.81, "10th_percentile": 1684.81, "90th_percentile": 1684.81, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1684.81, "10th_percentile": 1684.81, "90th_percentile": 1684.81, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1684.81, "10th_percentile": 1684.81, "90th_percentile": 1684.81, "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": 71.59, "maximum": 439.21, "setting": "outpatient", "gross_charge": 439.21, "discounted_cash": 307.45, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 272.31, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 272.31, "10th_percentile": 272.31, "90th_percentile": 272.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 272.31, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 272.31, "10th_percentile": 272.31, "90th_percentile": 272.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 126.67, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 126.67, "10th_percentile": 126.67, "90th_percentile": 126.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 306.22, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 306.22, "10th_percentile": 306.22, "90th_percentile": 306.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 124.21, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 124.21, "10th_percentile": 124.21, "90th_percentile": 124.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 245.52, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 245.52, "10th_percentile": 245.52, "90th_percentile": 245.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 158.29, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 158.29, "10th_percentile": 158.29, "90th_percentile": 158.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 122.98, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 122.98, "10th_percentile": 122.98, "90th_percentile": 122.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 395.29, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 395.29, "10th_percentile": 395.29, "90th_percentile": 395.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 395.29, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 395.29, "10th_percentile": 395.29, "90th_percentile": 395.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 219.61, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 219.61, "10th_percentile": 219.61, "90th_percentile": 219.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 285.49, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 285.49, "10th_percentile": 285.49, "90th_percentile": 285.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 329.41, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 329.41, "10th_percentile": 329.41, "90th_percentile": 329.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 373.33, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 373.33, "10th_percentile": 373.33, "90th_percentile": 373.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 298.22, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 298.22, "10th_percentile": 298.22, "90th_percentile": 298.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 439.21, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 439.21, "10th_percentile": 439.21, "90th_percentile": 439.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 351.37, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 351.37, "10th_percentile": 351.37, "90th_percentile": 351.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 208.19, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 208.19, "10th_percentile": 208.19, "90th_percentile": 208.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 231.46, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 231.46, "10th_percentile": 231.46, "90th_percentile": 231.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 439.21, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 439.21, "10th_percentile": 439.21, "90th_percentile": 439.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 282.1, "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": 282.1, "10th_percentile": 282.1, "90th_percentile": 282.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 329.41, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 329.41, "10th_percentile": 329.41, "90th_percentile": 329.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 95.75, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 95.75, "10th_percentile": 95.75, "90th_percentile": 95.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 351.37, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 351.37, "10th_percentile": 351.37, "90th_percentile": 351.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 215.21, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 215.21, "10th_percentile": 215.21, "90th_percentile": 215.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 219.61, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 219.61, "10th_percentile": 219.61, "90th_percentile": 219.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 306.22, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 306.22, "10th_percentile": 306.22, "90th_percentile": 306.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 303.05, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 303.05, "10th_percentile": 303.05, "90th_percentile": 303.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 71.59, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 71.59, "10th_percentile": 71.59, "90th_percentile": 71.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 158.29, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 158.29, "10th_percentile": 158.29, "90th_percentile": 158.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 276.7, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 276.7, "10th_percentile": 276.7, "90th_percentile": 276.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 439.21, "10th_percentile": 439.21, "90th_percentile": 439.21, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 439.21, "10th_percentile": 439.21, "90th_percentile": 439.21, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 439.21, "10th_percentile": 439.21, "90th_percentile": 439.21, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 439.21, "10th_percentile": 439.21, "90th_percentile": 439.21, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 439.21, "10th_percentile": 439.21, "90th_percentile": 439.21, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 439.21, "10th_percentile": 439.21, "90th_percentile": 439.21, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 439.21, "10th_percentile": 439.21, "90th_percentile": 439.21, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 439.21, "10th_percentile": 439.21, "90th_percentile": 439.21, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 439.21, "10th_percentile": 439.21, "90th_percentile": 439.21, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 439.21, "10th_percentile": 439.21, "90th_percentile": 439.21, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 439.21, "10th_percentile": 439.21, "90th_percentile": 439.21, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BONE CERV SPCR FRZN VG2 5.75X7.22MM TRAP", "code_information": [ { "code": "SUP-133361", "type": "CDM" }, { "code": "C1762", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 1154.66, "maximum": 7860.18, "setting": "outpatient", "gross_charge": 7860.18, "discounted_cash": 5502.13, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 1154.66, "standard_charge_percentage": 14.69, "standard_charge_algorithm": "Implant/Prosthetic Rev Code 278; 14.69% Billed", "median_amount": 1154.66, "10th_percentile": 1154.66, "90th_percentile": 1154.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Implant/Prosthetic Rev Code 278; 14.69% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 1154.66, "standard_charge_percentage": 14.69, "standard_charge_algorithm": "Implant/Prosthetic Rev Code 278; 14.69% Billed", "median_amount": 1154.66, "10th_percentile": 1154.66, "90th_percentile": 1154.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Implant/Prosthetic Rev Code 278; 14.69% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 1154.66, "standard_charge_percentage": 14.69, "standard_charge_algorithm": "Implant/Prosthetic Rev Code 278; 14.69% Billed", "median_amount": 1154.66, "10th_percentile": 1154.66, "90th_percentile": 1154.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Implant/Prosthetic Rev Code 278; 14.69% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 6681.15, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 6681.15, "10th_percentile": 6681.15, "90th_percentile": 6681.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 5109.12, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 5109.12, "10th_percentile": 5109.12, "90th_percentile": 5109.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 3930.09, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 3930.09, "10th_percentile": 3930.09, "90th_percentile": 3930.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 5895.14, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 5895.14, "10th_percentile": 5895.14, "90th_percentile": 5895.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 6288.14, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 6288.14, "10th_percentile": 6288.14, "90th_percentile": 6288.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 4951.91, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 4951.91, "10th_percentile": 4951.91, "90th_percentile": 4951.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 5423.52, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 5423.52, "10th_percentile": 5423.52, "90th_percentile": 5423.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 3930.09, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3930.09, "10th_percentile": 3930.09, "90th_percentile": 3930.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 5895.14, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 5895.14, "10th_percentile": 5895.14, "90th_percentile": 5895.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 4393.84, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4393.84, "10th_percentile": 4393.84, "90th_percentile": 4393.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 7860.18, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 7860.18, "10th_percentile": 7860.18, "90th_percentile": 7860.18, "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": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 1713.52, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1713.52, "10th_percentile": 1713.52, "90th_percentile": 1713.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 3725.73, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3725.73, "10th_percentile": 3725.73, "90th_percentile": 3725.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1414.83, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1414.83, "10th_percentile": 1414.83, "90th_percentile": 1414.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7860.18, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7860.18, "10th_percentile": 7860.18, "90th_percentile": 7860.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 6288.14, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 6288.14, "10th_percentile": 6288.14, "90th_percentile": 6288.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 5048.59, "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": 5048.59, "10th_percentile": 5048.59, "90th_percentile": 5048.59, "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": "DCH UHC HMO/PPO", "standard_charge_dollar": 4142.31, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4142.31, "10th_percentile": 4142.31, "90th_percentile": 4142.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 1281.21, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 1281.21, "10th_percentile": 1281.21, "90th_percentile": 1281.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 3851.49, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3851.49, "10th_percentile": 3851.49, "90th_percentile": 3851.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 5480.12, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5480.12, "10th_percentile": 5480.12, "90th_percentile": 5480.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 5480.12, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5480.12, "10th_percentile": 5480.12, "90th_percentile": 5480.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 1831.42, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 1831.42, "10th_percentile": 1831.42, "90th_percentile": 1831.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 1831.42, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 1831.42, "10th_percentile": 1831.42, "90th_percentile": 1831.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 7074.16, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 7074.16, "10th_percentile": 7074.16, "90th_percentile": 7074.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 7074.16, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 7074.16, "10th_percentile": 7074.16, "90th_percentile": 7074.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1171.17, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1171.17, "10th_percentile": 1171.17, "90th_percentile": 1171.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1171.17, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1171.17, "10th_percentile": 1171.17, "90th_percentile": 1171.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $7,860.18 @ 6.8% = $534.49 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": 534.49, "10th_percentile": 534.49, "90th_percentile": 534.49, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $7,860.18 @ 6.8% = $534.49 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": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $7,860.18 @ 6.8% = $534.49 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": 534.49, "10th_percentile": 534.49, "90th_percentile": 534.49, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $7,860.18 @ 6.8% = $534.49 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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $7,860.18 @ 6.8% = $534.49 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": 534.49, "10th_percentile": 534.49, "90th_percentile": 534.49, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $7,860.18 @ 6.8% = $534.49 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": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $7,860.18 @ 12.5% = $982.52 due to $0.00 Claim Price", "median_amount": 982.52, "10th_percentile": 982.52, "90th_percentile": 982.52, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $7,860.18 @ 12.5% = $982.52 due to $0.00 Claim Price" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 7860.18, "10th_percentile": 7860.18, "90th_percentile": 7860.18, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 7860.18, "10th_percentile": 7860.18, "90th_percentile": 7860.18, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 7860.18, "10th_percentile": 7860.18, "90th_percentile": 7860.18, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 7860.18, "10th_percentile": 7860.18, "90th_percentile": 7860.18, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 7860.18, "10th_percentile": 7860.18, "90th_percentile": 7860.18, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 7860.18, "10th_percentile": 7860.18, "90th_percentile": 7860.18, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 7860.18, "10th_percentile": 7860.18, "90th_percentile": 7860.18, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; 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": 90.05, "maximum": 552.47, "setting": "outpatient", "gross_charge": 552.47, "discounted_cash": 386.73, "payers_information": [ { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 342.53, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 342.53, "10th_percentile": 342.53, "90th_percentile": 342.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 497.22, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 497.22, "10th_percentile": 497.22, "90th_percentile": 497.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 441.98, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 441.98, "10th_percentile": 441.98, "90th_percentile": 441.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 441.98, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 441.98, "10th_percentile": 441.98, "90th_percentile": 441.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 469.6, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 469.6, "10th_percentile": 469.6, "90th_percentile": 469.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 359.11, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 359.11, "10th_percentile": 359.11, "90th_percentile": 359.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 276.24, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 276.24, "10th_percentile": 276.24, "90th_percentile": 276.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 414.35, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 414.35, "10th_percentile": 414.35, "90th_percentile": 414.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 261.87, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 261.87, "10th_percentile": 261.87, "90th_percentile": 261.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 276.24, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 276.24, "10th_percentile": 276.24, "90th_percentile": 276.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 270.71, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 270.71, "10th_percentile": 270.71, "90th_percentile": 270.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 354.85, "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": 354.85, "10th_percentile": 354.85, "90th_percentile": 354.85, "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": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 120.44, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 120.44, "10th_percentile": 120.44, "90th_percentile": 120.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH PHCS", "standard_charge_dollar": 414.35, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 414.35, "10th_percentile": 414.35, "90th_percentile": 414.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 552.47, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 552.47, "10th_percentile": 552.47, "90th_percentile": 552.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 291.15, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 291.15, "10th_percentile": 291.15, "90th_percentile": 291.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 552.47, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 552.47, "10th_percentile": 552.47, "90th_percentile": 552.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 381.2, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 381.2, "10th_percentile": 381.2, "90th_percentile": 381.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 348.06, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 348.06, "10th_percentile": 348.06, "90th_percentile": 348.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 552.47, "10th_percentile": 552.47, "90th_percentile": 552.47, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 552.47, "10th_percentile": 552.47, "90th_percentile": 552.47, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 552.47, "10th_percentile": 552.47, "90th_percentile": 552.47, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 552.47, "10th_percentile": 552.47, "90th_percentile": 552.47, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 552.47, "10th_percentile": 552.47, "90th_percentile": 552.47, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 552.47, "10th_percentile": 552.47, "90th_percentile": 552.47, "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": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 154.69, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 154.69, "10th_percentile": 154.69, "90th_percentile": 154.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 385.18, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 385.18, "10th_percentile": 385.18, "90th_percentile": 385.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 156.24, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 156.24, "10th_percentile": 156.24, "90th_percentile": 156.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 199.11, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 199.11, "10th_percentile": 199.11, "90th_percentile": 199.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 308.83, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 308.83, "10th_percentile": 308.83, "90th_percentile": 308.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 159.33, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 159.33, "10th_percentile": 159.33, "90th_percentile": 159.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 342.53, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 342.53, "10th_percentile": 342.53, "90th_percentile": 342.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 497.22, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 497.22, "10th_percentile": 497.22, "90th_percentile": 497.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 375.13, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 375.13, "10th_percentile": 375.13, "90th_percentile": 375.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 385.18, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 385.18, "10th_percentile": 385.18, "90th_percentile": 385.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 199.11, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 199.11, "10th_percentile": 199.11, "90th_percentile": 199.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 90.05, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 90.05, "10th_percentile": 90.05, "90th_percentile": 90.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 552.47, "10th_percentile": 552.47, "90th_percentile": 552.47, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 552.47, "10th_percentile": 552.47, "90th_percentile": 552.47, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 552.47, "10th_percentile": 552.47, "90th_percentile": 552.47, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 552.47, "10th_percentile": 552.47, "90th_percentile": 552.47, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 552.47, "10th_percentile": 552.47, "90th_percentile": 552.47, "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": 47.81, "maximum": 320.84, "setting": "outpatient", "gross_charge": 320.84, "discounted_cash": 224.59, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 320.84, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 320.84, "10th_percentile": 320.84, "90th_percentile": 320.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 288.76, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 288.76, "10th_percentile": 288.76, "90th_percentile": 288.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 240.63, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 240.63, "10th_percentile": 240.63, "90th_percentile": 240.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 206.08, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 206.08, "10th_percentile": 206.08, "90th_percentile": 206.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 152.08, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 152.08, "10th_percentile": 152.08, "90th_percentile": 152.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 169.08, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 169.08, "10th_percentile": 169.08, "90th_percentile": 169.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 320.84, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 320.84, "10th_percentile": 320.84, "90th_percentile": 320.84, "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": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 47.81, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 47.81, "10th_percentile": 47.81, "90th_percentile": 47.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 57.75, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 57.75, "10th_percentile": 57.75, "90th_percentile": 57.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 47.81, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 47.81, "10th_percentile": 47.81, "90th_percentile": 47.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 223.69, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 223.69, "10th_percentile": 223.69, "90th_percentile": 223.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 179.35, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 179.35, "10th_percentile": 179.35, "90th_percentile": 179.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 74.76, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 74.76, "10th_percentile": 74.76, "90th_percentile": 74.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 198.92, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 198.92, "10th_percentile": 198.92, "90th_percentile": 198.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 217.85, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 217.85, "10th_percentile": 217.85, "90th_percentile": 217.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 52.3, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 52.3, "10th_percentile": 52.3, "90th_percentile": 52.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 223.69, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 223.69, "10th_percentile": 223.69, "90th_percentile": 223.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 74.76, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 74.76, "10th_percentile": 74.76, "90th_percentile": 74.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 288.76, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 288.76, "10th_percentile": 288.76, "90th_percentile": 288.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 160.42, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 160.42, "10th_percentile": 160.42, "90th_percentile": 160.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 69.94, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 69.94, "10th_percentile": 69.94, "90th_percentile": 69.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 256.67, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 256.67, "10th_percentile": 256.67, "90th_percentile": 256.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 157.21, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 241.27, "10th_percentile": 241.27, "90th_percentile": 241.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 256.67, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 256.67, "10th_percentile": 256.67, "90th_percentile": 256.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 198.92, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 198.92, "10th_percentile": 198.92, "90th_percentile": 198.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 221.38, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 221.38, "10th_percentile": 221.38, "90th_percentile": 221.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 240.63, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 240.63, "10th_percentile": 240.63, "90th_percentile": 240.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 160.42, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 160.42, "10th_percentile": 160.42, "90th_percentile": 160.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 208.55, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 208.55, "10th_percentile": 208.55, "90th_percentile": 208.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 272.71, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 272.71, "10th_percentile": 272.71, "90th_percentile": 272.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 202.13, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 202.13, "10th_percentile": 202.13, "90th_percentile": 202.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $320.84 @ 12.5% = $40.11 due to $0.00 Claim Price", "median_amount": 40.11, "10th_percentile": 40.11, "90th_percentile": 40.11, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $320.84 @ 12.5% = $40.11 due to $0.00 Claim Price" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $320.84 @ 6.8% = $21.82 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": 21.82, "10th_percentile": 21.82, "90th_percentile": 21.82, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $320.84 @ 6.8% = $21.82 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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $320.84 @ 6.8% = $21.82 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": 21.82, "10th_percentile": 21.82, "90th_percentile": 21.82, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $320.84 @ 6.8% = $21.82 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $320.84 @ 6.8% = $21.82 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": 21.82, "10th_percentile": 21.82, "90th_percentile": 21.82, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $320.84 @ 6.8% = $21.82 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": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 320.84, "10th_percentile": 320.84, "90th_percentile": 320.84, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 320.84, "10th_percentile": 320.84, "90th_percentile": 320.84, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 320.84, "10th_percentile": 320.84, "90th_percentile": 320.84, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 320.84, "10th_percentile": 320.84, "90th_percentile": 320.84, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 320.84, "10th_percentile": 320.84, "90th_percentile": 320.84, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 320.84, "10th_percentile": 320.84, "90th_percentile": 320.84, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 320.84, "10th_percentile": 320.84, "90th_percentile": 320.84, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BREASTBINDER L LINED 2XL/L", "code_information": [ { "code": "SUP-300323", "type": "CDM" }, { "code": "27000001", "type": "LOCAL" }, { "code": "0270", "type": "RC" } ], "standard_charges": [ { "minimum": 36.72, "maximum": 225.28, "setting": "outpatient", "gross_charge": 225.28, "discounted_cash": 157.7, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 225.28, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 225.28, "10th_percentile": 225.28, "90th_percentile": 225.28, "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": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 64.97, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 64.97, "10th_percentile": 64.97, "90th_percentile": 64.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 63.71, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 63.71, "10th_percentile": 63.71, "90th_percentile": 63.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 63.08, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 157.07, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 157.07, "10th_percentile": 157.07, "90th_percentile": 157.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 125.93, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 125.93, "10th_percentile": 125.93, "90th_percentile": 125.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 81.19, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 81.19, "10th_percentile": 81.19, "90th_percentile": 81.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 152.97, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 152.97, "10th_percentile": 152.97, "90th_percentile": 152.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 36.72, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% 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 Services; 16.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 139.67, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 139.67, "10th_percentile": 139.67, "90th_percentile": 139.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 157.07, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 157.07, "10th_percentile": 157.07, "90th_percentile": 157.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 81.19, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 81.19, "10th_percentile": 81.19, "90th_percentile": 81.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 202.75, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 202.75, "10th_percentile": 202.75, "90th_percentile": 202.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 112.64, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 112.64, "10th_percentile": 112.64, "90th_percentile": 112.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 49.11, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 49.11, "10th_percentile": 49.11, "90th_percentile": 49.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 180.22, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 180.22, "10th_percentile": 180.22, "90th_percentile": 180.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 110.39, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 110.39, "10th_percentile": 110.39, "90th_percentile": 110.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 180.22, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 180.22, "10th_percentile": 180.22, "90th_percentile": 180.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 139.67, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 139.67, "10th_percentile": 139.67, "90th_percentile": 139.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 155.44, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 155.44, "10th_percentile": 155.44, "90th_percentile": 155.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 168.96, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 168.96, "10th_percentile": 168.96, "90th_percentile": 168.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 112.64, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 112.64, "10th_percentile": 112.64, "90th_percentile": 112.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 146.43, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 146.43, "10th_percentile": 146.43, "90th_percentile": 146.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 191.49, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 191.49, "10th_percentile": 191.49, "90th_percentile": 191.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 141.93, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 141.93, "10th_percentile": 141.93, "90th_percentile": 141.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 202.75, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 202.75, "10th_percentile": 202.75, "90th_percentile": 202.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 168.96, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 168.96, "10th_percentile": 168.96, "90th_percentile": 168.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 144.7, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 144.7, "10th_percentile": 144.7, "90th_percentile": 144.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - 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": "DCH UHC CORE", "standard_charge_dollar": 106.78, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 106.78, "10th_percentile": 106.78, "90th_percentile": 106.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 118.72, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 118.72, "10th_percentile": 118.72, "90th_percentile": 118.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 225.28, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 225.28, "10th_percentile": 225.28, "90th_percentile": 225.28, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 225.28, "10th_percentile": 225.28, "90th_percentile": 225.28, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 225.28, "10th_percentile": 225.28, "90th_percentile": 225.28, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 225.28, "10th_percentile": 225.28, "90th_percentile": 225.28, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 225.28, "10th_percentile": 225.28, "90th_percentile": 225.28, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 225.28, "10th_percentile": 225.28, "90th_percentile": 225.28, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 225.28, "10th_percentile": 225.28, "90th_percentile": 225.28, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 225.28, "10th_percentile": 225.28, "90th_percentile": 225.28, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 225.28, "10th_percentile": 225.28, "90th_percentile": 225.28, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 225.28, "10th_percentile": 225.28, "90th_percentile": 225.28, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 225.28, "10th_percentile": 225.28, "90th_percentile": 225.28, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 225.28, "10th_percentile": 225.28, "90th_percentile": 225.28, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BRUSH CYTO COLONSCP", "code_information": [ { "code": "SUP-143740", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 201.04, "maximum": 1233.38, "setting": "outpatient", "gross_charge": 1233.38, "discounted_cash": 863.37, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 355.71, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 355.71, "10th_percentile": 355.71, "90th_percentile": 355.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 345.35, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 345.35, "10th_percentile": 345.35, "90th_percentile": 345.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 444.51, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 444.51, "10th_percentile": 444.51, "90th_percentile": 444.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 689.46, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 689.46, "10th_percentile": 689.46, "90th_percentile": 689.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 348.8, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 348.8, "10th_percentile": 348.8, "90th_percentile": 348.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 859.91, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 859.91, "10th_percentile": 859.91, "90th_percentile": 859.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 764.7, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 764.7, "10th_percentile": 764.7, "90th_percentile": 764.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 764.7, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 764.7, "10th_percentile": 764.7, "90th_percentile": 764.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 1110.04, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 1110.04, "10th_percentile": 1110.04, "90th_percentile": 1110.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 1110.04, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 1110.04, "10th_percentile": 1110.04, "90th_percentile": 1110.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 616.69, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 616.69, "10th_percentile": 616.69, "90th_percentile": 616.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 801.7, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 801.7, "10th_percentile": 801.7, "90th_percentile": 801.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 925.04, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 925.04, "10th_percentile": 925.04, "90th_percentile": 925.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 1048.37, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 1048.37, "10th_percentile": 1048.37, "90th_percentile": 1048.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 444.51, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 444.51, "10th_percentile": 444.51, "90th_percentile": 444.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 584.62, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 584.62, "10th_percentile": 584.62, "90th_percentile": 584.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1233.38, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1233.38, "10th_percentile": 1233.38, "90th_percentile": 1233.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 649.99, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 649.99, "10th_percentile": 649.99, "90th_percentile": 649.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 777.03, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 777.03, "10th_percentile": 777.03, "90th_percentile": 777.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 268.88, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 268.88, "10th_percentile": 268.88, "90th_percentile": 268.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 604.36, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 604.36, "10th_percentile": 604.36, "90th_percentile": 604.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 986.7, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 986.7, "10th_percentile": 986.7, "90th_percentile": 986.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 616.69, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 616.69, "10th_percentile": 616.69, "90th_percentile": 616.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 201.04, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 201.04, "10th_percentile": 201.04, "90th_percentile": 201.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 986.7, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 986.7, "10th_percentile": 986.7, "90th_percentile": 986.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 792.2, "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": 792.2, "10th_percentile": 792.2, "90th_percentile": 792.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 925.04, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 925.04, "10th_percentile": 925.04, "90th_percentile": 925.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 859.91, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 859.91, "10th_percentile": 859.91, "90th_percentile": 859.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 851.03, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 851.03, "10th_percentile": 851.03, "90th_percentile": 851.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 837.47, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 837.47, "10th_percentile": 837.47, "90th_percentile": 837.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1233.38, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1233.38, "10th_percentile": 1233.38, "90th_percentile": 1233.38, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 1233.38, "10th_percentile": 1233.38, "90th_percentile": 1233.38, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1233.38, "10th_percentile": 1233.38, "90th_percentile": 1233.38, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1233.38, "10th_percentile": 1233.38, "90th_percentile": 1233.38, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1233.38, "10th_percentile": 1233.38, "90th_percentile": 1233.38, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1233.38, "10th_percentile": 1233.38, "90th_percentile": 1233.38, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1233.38, "10th_percentile": 1233.38, "90th_percentile": 1233.38, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1233.38, "10th_percentile": 1233.38, "90th_percentile": 1233.38, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1233.38, "10th_percentile": 1233.38, "90th_percentile": 1233.38, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1233.38, "10th_percentile": 1233.38, "90th_percentile": 1233.38, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1233.38, "10th_percentile": 1233.38, "90th_percentile": 1233.38, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1233.38, "10th_percentile": 1233.38, "90th_percentile": 1233.38, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BRUSH CYTOLOGY GI LAB BILIARY FUSION 1.5CM FILF G31525", "code_information": [ { "code": "SUP-302581", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 145.95, "maximum": 895.41, "setting": "outpatient", "gross_charge": 895.41, "discounted_cash": 626.79, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 250.71, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 250.71, "10th_percentile": 250.71, "90th_percentile": 250.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 322.71, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 322.71, "10th_percentile": 322.71, "90th_percentile": 322.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 500.53, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 500.53, "10th_percentile": 500.53, "90th_percentile": 500.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 253.22, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 253.22, "10th_percentile": 253.22, "90th_percentile": 253.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 624.28, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 624.28, "10th_percentile": 624.28, "90th_percentile": 624.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 555.15, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 555.15, "10th_percentile": 555.15, "90th_percentile": 555.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 805.87, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 805.87, "10th_percentile": 805.87, "90th_percentile": 805.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 447.71, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 447.71, "10th_percentile": 447.71, "90th_percentile": 447.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 582.02, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 582.02, "10th_percentile": 582.02, "90th_percentile": 582.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 671.56, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 671.56, "10th_percentile": 671.56, "90th_percentile": 671.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 761.1, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 761.1, "10th_percentile": 761.1, "90th_percentile": 761.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 424.42, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 424.42, "10th_percentile": 424.42, "90th_percentile": 424.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 895.41, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 895.41, "10th_percentile": 895.41, "90th_percentile": 895.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 471.88, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 471.88, "10th_percentile": 471.88, "90th_percentile": 471.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 564.11, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 564.11, "10th_percentile": 564.11, "90th_percentile": 564.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 195.2, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 195.2, "10th_percentile": 195.2, "90th_percentile": 195.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 438.75, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 438.75, "10th_percentile": 438.75, "90th_percentile": 438.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 716.33, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 716.33, "10th_percentile": 716.33, "90th_percentile": 716.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 447.71, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 447.71, "10th_percentile": 447.71, "90th_percentile": 447.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 716.33, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 716.33, "10th_percentile": 716.33, "90th_percentile": 716.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 575.12, "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": 575.12, "10th_percentile": 575.12, "90th_percentile": 575.12, "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": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 671.56, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 671.56, "10th_percentile": 671.56, "90th_percentile": 671.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 617.83, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 617.83, "10th_percentile": 617.83, "90th_percentile": 617.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 895.41, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 895.41, "10th_percentile": 895.41, "90th_percentile": 895.41, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 895.41, "10th_percentile": 895.41, "90th_percentile": 895.41, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 895.41, "10th_percentile": 895.41, "90th_percentile": 895.41, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 895.41, "10th_percentile": 895.41, "90th_percentile": 895.41, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 895.41, "10th_percentile": 895.41, "90th_percentile": 895.41, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 895.41, "10th_percentile": 895.41, "90th_percentile": 895.41, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 895.41, "10th_percentile": 895.41, "90th_percentile": 895.41, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 895.41, "10th_percentile": 895.41, "90th_percentile": 895.41, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 258.24, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 258.24, "10th_percentile": 258.24, "90th_percentile": 258.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 805.87, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 805.87, "10th_percentile": 805.87, "90th_percentile": 805.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 607.98, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 607.98, "10th_percentile": 607.98, "90th_percentile": 607.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 624.28, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 624.28, "10th_percentile": 624.28, "90th_percentile": 624.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 145.95, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 145.95, "10th_percentile": 145.95, "90th_percentile": 145.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 322.71, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 322.71, "10th_percentile": 322.71, "90th_percentile": 322.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 555.15, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 555.15, "10th_percentile": 555.15, "90th_percentile": 555.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 895.41, "10th_percentile": 895.41, "90th_percentile": 895.41, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 895.41, "10th_percentile": 895.41, "90th_percentile": 895.41, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 895.41, "10th_percentile": 895.41, "90th_percentile": 895.41, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 895.41, "10th_percentile": 895.41, "90th_percentile": 895.41, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN", "drug_information": { "unit": 5.0, "type": "ML" }, "code_information": [ { "code": "RX-92832", "type": "CDM" }, { "code": "J0665", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "00143-9331-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.2, "maximum": 14.75, "setting": "outpatient", "gross_charge": 14.75, "discounted_cash": 10.32, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 14.75, "10th_percentile": 14.75, "90th_percentile": 14.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 14.75, "10th_percentile": 14.75, "90th_percentile": 14.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 14.75, "10th_percentile": 14.75, "90th_percentile": 14.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 14.75, "10th_percentile": 14.75, "90th_percentile": 14.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $14.75 @ 6.8% = $1.00 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": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $14.75 @ 6.8% = $1.00 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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 3.44, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 3.44, "10th_percentile": 3.44, "90th_percentile": 3.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 2.66, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.66, "10th_percentile": 2.66, "90th_percentile": 2.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 8.25, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.25, "10th_percentile": 8.25, "90th_percentile": 8.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 10.28, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.28, "10th_percentile": 10.28, "90th_percentile": 10.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 2.2, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.2, "10th_percentile": 2.2, "90th_percentile": 2.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 2.2, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.2, "10th_percentile": 2.2, "90th_percentile": 2.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 13.28, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 13.28, "10th_percentile": 13.28, "90th_percentile": 13.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 10.28, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.28, "10th_percentile": 10.28, "90th_percentile": 10.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 7.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.38, "10th_percentile": 7.38, "90th_percentile": 7.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 2.4, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% 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; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 3.44, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 3.44, "10th_percentile": 3.44, "90th_percentile": 3.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 14.75, "10th_percentile": 14.75, "90th_percentile": 14.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 14.75, "10th_percentile": 14.75, "90th_percentile": 14.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 14.75, "10th_percentile": 14.75, "90th_percentile": 14.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $14.75 @ 12.5% = $1.84 due to $0.00 Claim Price", "median_amount": 1.84, "10th_percentile": 1.84, "90th_percentile": 1.84, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $14.75 @ 12.5% = $1.84 due to $0.00 Claim Price" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $14.75 @ 6.8% = $1.00 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": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $14.75 @ 6.8% = $1.00 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $14.75 @ 6.8% = $1.00 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": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $14.75 @ 6.8% = $1.00 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": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 13.28, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 13.28, "10th_percentile": 13.28, "90th_percentile": 13.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 12.54, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 12.54, "10th_percentile": 12.54, "90th_percentile": 12.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 7.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 7.38, "10th_percentile": 7.38, "90th_percentile": 7.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 11.06, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 11.06, "10th_percentile": 11.06, "90th_percentile": 11.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 9.59, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 9.59, "10th_percentile": 9.59, "90th_percentile": 9.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 9.29, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 9.29, "10th_percentile": 9.29, "90th_percentile": 9.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 11.06, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 11.06, "10th_percentile": 11.06, "90th_percentile": 11.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 11.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 11.8, "10th_percentile": 11.8, "90th_percentile": 11.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 10.18, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 10.18, "10th_percentile": 10.18, "90th_percentile": 10.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 14.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 14.75, "10th_percentile": 14.75, "90th_percentile": 14.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 11.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 11.8, "10th_percentile": 11.8, "90th_percentile": 11.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 14.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 14.75, "10th_percentile": 14.75, "90th_percentile": 14.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN", "drug_information": { "unit": 5.0, "type": "ML" }, "code_information": [ { "code": "RX-92832", "type": "CDM" }, { "code": "J0665", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "00409-1162-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.32, "maximum": 29.0, "setting": "outpatient", "gross_charge": 29.0, "discounted_cash": 20.3, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 29.0, "10th_percentile": 29.0, "90th_percentile": 29.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 29.0, "10th_percentile": 29.0, "90th_percentile": 29.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 29.0, "10th_percentile": 29.0, "90th_percentile": 29.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 29.0, "10th_percentile": 29.0, "90th_percentile": 29.0, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 29.0, "10th_percentile": 29.0, "90th_percentile": 29.0, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 29.0, "10th_percentile": 29.0, "90th_percentile": 29.0, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 29.0, "10th_percentile": 29.0, "90th_percentile": 29.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $29.00 @ 6.8% = $1.97 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": 1.97, "10th_percentile": 1.97, "90th_percentile": 1.97, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $29.00 @ 6.8% = $1.97 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $29.00 @ 6.8% = $1.97 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": 1.97, "10th_percentile": 1.97, "90th_percentile": 1.97, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $29.00 @ 6.8% = $1.97 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": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $29.00 @ 6.8% = $1.97 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": 1.97, "10th_percentile": 1.97, "90th_percentile": 1.97, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $29.00 @ 6.8% = $1.97 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": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $29.00 @ 12.5% = $3.63 due to $0.00 Claim Price", "median_amount": 3.63, "10th_percentile": 3.63, "90th_percentile": 3.63, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $29.00 @ 12.5% = $3.63 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 6.76, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 6.76, "10th_percentile": 6.76, "90th_percentile": 6.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 6.76, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 6.76, "10th_percentile": 6.76, "90th_percentile": 6.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 4.32, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.32, "10th_percentile": 4.32, "90th_percentile": 4.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 4.32, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.32, "10th_percentile": 4.32, "90th_percentile": 4.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 20.22, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.22, "10th_percentile": 20.22, "90th_percentile": 20.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 20.22, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.22, "10th_percentile": 20.22, "90th_percentile": 20.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 26.1, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 26.1, "10th_percentile": 26.1, "90th_percentile": 26.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 26.1, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 26.1, "10th_percentile": 26.1, "90th_percentile": 26.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 14.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 14.5, "10th_percentile": 14.5, "90th_percentile": 14.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 24.65, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 24.65, "10th_percentile": 24.65, "90th_percentile": 24.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 18.85, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 18.85, "10th_percentile": 18.85, "90th_percentile": 18.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 21.75, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 21.75, "10th_percentile": 21.75, "90th_percentile": 21.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 18.27, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 18.27, "10th_percentile": 18.27, "90th_percentile": 18.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 29.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 29.0, "10th_percentile": 29.0, "90th_percentile": 29.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 21.75, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 21.75, "10th_percentile": 21.75, "90th_percentile": 21.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 14.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14.5, "10th_percentile": 14.5, "90th_percentile": 14.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 23.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 23.2, "10th_percentile": 23.2, "90th_percentile": 23.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 20.01, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 20.01, "10th_percentile": 20.01, "90th_percentile": 20.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 29.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 29.0, "10th_percentile": 29.0, "90th_percentile": 29.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 23.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 23.2, "10th_percentile": 23.2, "90th_percentile": 23.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 16.21, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.21, "10th_percentile": 16.21, "90th_percentile": 16.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 4.73, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 4.73, "10th_percentile": 4.73, "90th_percentile": 4.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 5.22, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.22, "10th_percentile": 5.22, "90th_percentile": 5.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "BUPIVACAINE (PF) LOCAL INFILTRATION INFUSION 0.25% 275 ML", "drug_information": { "unit": 10.0, "type": "ML" }, "code_information": [ { "code": "RX-4080000209", "type": "CDM" }, { "code": "J0665", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "63323-0464-17", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.66, "maximum": 31.25, "setting": "outpatient", "gross_charge": 31.25, "discounted_cash": 21.87, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 31.25, "10th_percentile": 31.25, "90th_percentile": 31.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 31.25, "10th_percentile": 31.25, "90th_percentile": 31.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 31.25, "10th_percentile": 31.25, "90th_percentile": 31.25, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 31.25, "10th_percentile": 31.25, "90th_percentile": 31.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 31.25, "10th_percentile": 31.25, "90th_percentile": 31.25, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 31.25, "10th_percentile": 31.25, "90th_percentile": 31.25, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 31.25, "10th_percentile": 31.25, "90th_percentile": 31.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $31.25 @ 12.5% = $3.91 due to $0.00 Claim Price", "median_amount": 3.91, "10th_percentile": 3.91, "90th_percentile": 3.91, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $31.25 @ 12.5% = $3.91 due to $0.00 Claim Price" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $31.25 @ 6.8% = $2.13 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": 2.13, "10th_percentile": 2.13, "90th_percentile": 2.13, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $31.25 @ 6.8% = $2.13 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $31.25 @ 6.8% = $2.13 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": 2.13, "10th_percentile": 2.13, "90th_percentile": 2.13, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $31.25 @ 6.8% = $2.13 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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $31.25 @ 6.8% = $2.13 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": 2.13, "10th_percentile": 2.13, "90th_percentile": 2.13, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $31.25 @ 6.8% = $2.13 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 BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 21.79, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 21.79, "10th_percentile": 21.79, "90th_percentile": 21.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 21.79, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 21.79, "10th_percentile": 21.79, "90th_percentile": 21.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 7.28, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 7.28, "10th_percentile": 7.28, "90th_percentile": 7.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 7.28, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 7.28, "10th_percentile": 7.28, "90th_percentile": 7.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 28.13, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 28.13, "10th_percentile": 28.13, "90th_percentile": 28.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 28.13, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 28.13, "10th_percentile": 28.13, "90th_percentile": 28.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 4.66, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.66, "10th_percentile": 4.66, "90th_percentile": 4.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 4.66, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.66, "10th_percentile": 4.66, "90th_percentile": 4.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH HFN PPO", "standard_charge_dollar": 26.56, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 26.56, "10th_percentile": 26.56, "90th_percentile": 26.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 15.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 15.63, "10th_percentile": 15.63, "90th_percentile": 15.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 23.44, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 23.44, "10th_percentile": 23.44, "90th_percentile": 23.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 20.31, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 20.31, "10th_percentile": 20.31, "90th_percentile": 20.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 15.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15.63, "10th_percentile": 15.63, "90th_percentile": 15.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 17.47, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 17.47, "10th_percentile": 17.47, "90th_percentile": 17.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 19.69, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 19.69, "10th_percentile": 19.69, "90th_percentile": 19.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 23.44, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 23.44, "10th_percentile": 23.44, "90th_percentile": 23.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 25.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 25.0, "10th_percentile": 25.0, "90th_percentile": 25.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 21.56, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 21.56, "10th_percentile": 21.56, "90th_percentile": 21.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 31.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 31.25, "10th_percentile": 31.25, "90th_percentile": 31.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 25.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 25.0, "10th_percentile": 25.0, "90th_percentile": 25.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 31.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 31.25, "10th_percentile": 31.25, "90th_percentile": 31.25, "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": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 5.63, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.63, "10th_percentile": 5.63, "90th_percentile": 5.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 5.09, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 5.09, "10th_percentile": 5.09, "90th_percentile": 5.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" } ] } ] }, { "description": "BUPIVACAINE HCL 0.5 % (5 MG/ML) INJ SOLN", "drug_information": { "unit": 50.0, "type": "ML" }, "code_information": [ { "code": "RX-1223", "type": "CDM" }, { "code": "J0665", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "00409-1163-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 8.34, "maximum": 56.0, "setting": "outpatient", "gross_charge": 56.0, "discounted_cash": 39.2, "payers_information": [ { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 56.0, "10th_percentile": 56.0, "90th_percentile": 56.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 56.0, "10th_percentile": 56.0, "90th_percentile": 56.0, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 56.0, "10th_percentile": 56.0, "90th_percentile": 56.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $56.00 @ 12.5% = $7.00 due to $0.00 Claim Price", "median_amount": 7.0, "10th_percentile": 7.0, "90th_percentile": 7.0, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $56.00 @ 12.5% = $7.00 due to $0.00 Claim Price" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $56.00 @ 6.8% = $3.81 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": 3.81, "10th_percentile": 3.81, "90th_percentile": 3.81, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $56.00 @ 6.8% = $3.81 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $56.00 @ 6.8% = $3.81 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": 3.81, "10th_percentile": 3.81, "90th_percentile": 3.81, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $56.00 @ 6.8% = $3.81 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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $56.00 @ 6.8% = $3.81 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": 3.81, "10th_percentile": 3.81, "90th_percentile": 3.81, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $56.00 @ 6.8% = $3.81 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": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 50.4, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 50.4, "10th_percentile": 50.4, "90th_percentile": 50.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 36.4, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 36.4, "10th_percentile": 36.4, "90th_percentile": 36.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 42.0, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 42.0, "10th_percentile": 42.0, "90th_percentile": 42.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 28.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 28.0, "10th_percentile": 28.0, "90th_percentile": 28.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 47.6, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 47.6, "10th_percentile": 47.6, "90th_percentile": 47.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 38.64, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 38.64, "10th_percentile": 38.64, "90th_percentile": 38.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 44.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 44.8, "10th_percentile": 44.8, "90th_percentile": 44.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 28.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 28.0, "10th_percentile": 28.0, "90th_percentile": 28.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 42.0, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 42.0, "10th_percentile": 42.0, "90th_percentile": 42.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 35.28, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 35.28, "10th_percentile": 35.28, "90th_percentile": 35.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 44.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 44.8, "10th_percentile": 44.8, "90th_percentile": 44.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 56.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 56.0, "10th_percentile": 56.0, "90th_percentile": 56.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 56.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 56.0, "10th_percentile": 56.0, "90th_percentile": 56.0, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 56.0, "10th_percentile": 56.0, "90th_percentile": 56.0, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 56.0, "10th_percentile": 56.0, "90th_percentile": 56.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 56.0, "10th_percentile": 56.0, "90th_percentile": 56.0, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 56.0, "10th_percentile": 56.0, "90th_percentile": 56.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 39.04, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 39.04, "10th_percentile": 39.04, "90th_percentile": 39.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 39.04, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 39.04, "10th_percentile": 39.04, "90th_percentile": 39.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 13.05, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 13.05, "10th_percentile": 13.05, "90th_percentile": 13.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 13.05, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 13.05, "10th_percentile": 13.05, "90th_percentile": 13.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 50.4, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 50.4, "10th_percentile": 50.4, "90th_percentile": 50.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 8.34, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.34, "10th_percentile": 8.34, "90th_percentile": 8.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 8.34, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.34, "10th_percentile": 8.34, "90th_percentile": 8.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 31.3, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 31.3, "10th_percentile": 31.3, "90th_percentile": 31.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 10.08, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.08, "10th_percentile": 10.08, "90th_percentile": 10.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 9.13, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 9.13, "10th_percentile": 9.13, "90th_percentile": 9.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" } ] } ] }, { "description": "BUPRENORPHINE-NALOXONE 2-0.5 MG SL FILM", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-184165", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "43598-0579-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.46, "maximum": 45.75, "setting": "outpatient", "gross_charge": 45.75, "discounted_cash": 32.02, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 12.81, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.81, "10th_percentile": 12.81, "90th_percentile": 12.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 25.57, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 25.57, "10th_percentile": 25.57, "90th_percentile": 25.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 16.49, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.49, "10th_percentile": 16.49, "90th_percentile": 16.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 12.94, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 13.19, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13.19, "10th_percentile": 13.19, "90th_percentile": 13.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 31.9, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 31.9, "10th_percentile": 31.9, "90th_percentile": 31.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 28.37, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 28.37, "10th_percentile": 28.37, "90th_percentile": 28.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 28.37, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 28.37, "10th_percentile": 28.37, "90th_percentile": 28.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 41.18, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 41.18, "10th_percentile": 41.18, "90th_percentile": 41.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 41.18, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 41.18, "10th_percentile": 41.18, "90th_percentile": 41.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 38.89, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 38.89, "10th_percentile": 38.89, "90th_percentile": 38.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 34.31, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 34.31, "10th_percentile": 34.31, "90th_percentile": 34.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 29.74, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 29.74, "10th_percentile": 29.74, "90th_percentile": 29.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 22.88, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 22.88, "10th_percentile": 22.88, "90th_percentile": 22.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 7.46, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 7.46, "10th_percentile": 7.46, "90th_percentile": 7.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 31.06, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 31.06, "10th_percentile": 31.06, "90th_percentile": 31.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 31.9, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 31.9, "10th_percentile": 31.9, "90th_percentile": 31.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 16.49, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.49, "10th_percentile": 16.49, "90th_percentile": 16.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 22.42, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 22.42, "10th_percentile": 22.42, "90th_percentile": 22.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 22.88, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 22.88, "10th_percentile": 22.88, "90th_percentile": 22.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 45.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 45.75, "10th_percentile": 45.75, "90th_percentile": 45.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 36.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 36.6, "10th_percentile": 36.6, "90th_percentile": 36.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 24.11, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 24.11, "10th_percentile": 24.11, "90th_percentile": 24.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 21.69, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 21.69, "10th_percentile": 21.69, "90th_percentile": 21.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 28.82, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 28.82, "10th_percentile": 28.82, "90th_percentile": 28.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 31.57, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 31.57, "10th_percentile": 31.57, "90th_percentile": 31.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 29.39, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 29.39, "10th_percentile": 29.39, "90th_percentile": 29.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 34.31, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 34.31, "10th_percentile": 34.31, "90th_percentile": 34.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 9.97, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.97, "10th_percentile": 9.97, "90th_percentile": 9.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 45.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 45.75, "10th_percentile": 45.75, "90th_percentile": 45.75, "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": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 36.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 36.6, "10th_percentile": 36.6, "90th_percentile": 36.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 45.75, "10th_percentile": 45.75, "90th_percentile": 45.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 45.75, "10th_percentile": 45.75, "90th_percentile": 45.75, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 45.75, "10th_percentile": 45.75, "90th_percentile": 45.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 45.75, "10th_percentile": 45.75, "90th_percentile": 45.75, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 45.75, "10th_percentile": 45.75, "90th_percentile": 45.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 45.75, "10th_percentile": 45.75, "90th_percentile": 45.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 45.75, "10th_percentile": 45.75, "90th_percentile": 45.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 45.75, "10th_percentile": 45.75, "90th_percentile": 45.75, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 45.75, "10th_percentile": 45.75, "90th_percentile": 45.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 45.75, "10th_percentile": 45.75, "90th_percentile": 45.75, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 45.75, "10th_percentile": 45.75, "90th_percentile": 45.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BUPRENORPHINE-NALOXONE 2-0.5 MG SL FILM", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-184165", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "43598-0579-30", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.46, "maximum": 45.75, "setting": "outpatient", "gross_charge": 45.75, "discounted_cash": 32.02, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 45.75, "10th_percentile": 45.75, "90th_percentile": 45.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 45.75, "10th_percentile": 45.75, "90th_percentile": 45.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 45.75, "10th_percentile": 45.75, "90th_percentile": 45.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 45.75, "10th_percentile": 45.75, "90th_percentile": 45.75, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 45.75, "10th_percentile": 45.75, "90th_percentile": 45.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 28.37, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 28.37, "10th_percentile": 28.37, "90th_percentile": 28.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 41.18, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 41.18, "10th_percentile": 41.18, "90th_percentile": 41.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 34.31, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 34.31, "10th_percentile": 34.31, "90th_percentile": 34.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 29.74, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 29.74, "10th_percentile": 29.74, "90th_percentile": 29.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 22.88, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 22.88, "10th_percentile": 22.88, "90th_percentile": 22.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 38.89, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 38.89, "10th_percentile": 38.89, "90th_percentile": 38.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 21.69, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 21.69, "10th_percentile": 21.69, "90th_percentile": 21.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 24.11, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 24.11, "10th_percentile": 24.11, "90th_percentile": 24.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 45.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 45.75, "10th_percentile": 45.75, "90th_percentile": 45.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 45.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 45.75, "10th_percentile": 45.75, "90th_percentile": 45.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 29.39, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 29.39, "10th_percentile": 29.39, "90th_percentile": 29.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 28.82, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 28.82, "10th_percentile": 28.82, "90th_percentile": 28.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 31.57, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 31.57, "10th_percentile": 31.57, "90th_percentile": 31.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 34.31, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 34.31, "10th_percentile": 34.31, "90th_percentile": 34.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 12.81, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.81, "10th_percentile": 12.81, "90th_percentile": 12.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 25.57, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 25.57, "10th_percentile": 25.57, "90th_percentile": 25.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 16.49, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.49, "10th_percentile": 16.49, "90th_percentile": 16.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 12.94, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 13.19, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13.19, "10th_percentile": 13.19, "90th_percentile": 13.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 31.9, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 31.9, "10th_percentile": 31.9, "90th_percentile": 31.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 28.37, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 28.37, "10th_percentile": 28.37, "90th_percentile": 28.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 41.18, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 41.18, "10th_percentile": 41.18, "90th_percentile": 41.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 7.46, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 7.46, "10th_percentile": 7.46, "90th_percentile": 7.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 31.06, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 31.06, "10th_percentile": 31.06, "90th_percentile": 31.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 31.9, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 31.9, "10th_percentile": 31.9, "90th_percentile": 31.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 16.49, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.49, "10th_percentile": 16.49, "90th_percentile": 16.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 22.42, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 22.42, "10th_percentile": 22.42, "90th_percentile": 22.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 22.88, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 22.88, "10th_percentile": 22.88, "90th_percentile": 22.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 36.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 36.6, "10th_percentile": 36.6, "90th_percentile": 36.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 9.97, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.97, "10th_percentile": 9.97, "90th_percentile": 9.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 36.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 36.6, "10th_percentile": 36.6, "90th_percentile": 36.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 45.75, "10th_percentile": 45.75, "90th_percentile": 45.75, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 45.75, "10th_percentile": 45.75, "90th_percentile": 45.75, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 45.75, "10th_percentile": 45.75, "90th_percentile": 45.75, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 45.75, "10th_percentile": 45.75, "90th_percentile": 45.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 45.75, "10th_percentile": 45.75, "90th_percentile": 45.75, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 45.75, "10th_percentile": 45.75, "90th_percentile": 45.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BUPRENORPHINE-NALOXONE 8-2 MG SL FILM", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-184166", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "43598-0582-30", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.36, "maximum": 39.0, "setting": "outpatient", "gross_charge": 39.0, "discounted_cash": 27.3, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 10.92, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.92, "10th_percentile": 10.92, "90th_percentile": 10.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 21.8, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 21.8, "10th_percentile": 21.8, "90th_percentile": 21.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 14.06, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14.06, "10th_percentile": 14.06, "90th_percentile": 14.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 11.03, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.03, "10th_percentile": 11.03, "90th_percentile": 11.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 11.25, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 27.19, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 27.19, "10th_percentile": 27.19, "90th_percentile": 27.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 24.18, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 24.18, "10th_percentile": 24.18, "90th_percentile": 24.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 24.18, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 24.18, "10th_percentile": 24.18, "90th_percentile": 24.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 35.1, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 35.1, "10th_percentile": 35.1, "90th_percentile": 35.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 29.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 29.25, "10th_percentile": 29.25, "90th_percentile": 29.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 6.36, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 6.36, "10th_percentile": 6.36, "90th_percentile": 6.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 26.48, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 26.48, "10th_percentile": 26.48, "90th_percentile": 26.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 27.19, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 27.19, "10th_percentile": 27.19, "90th_percentile": 27.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 14.06, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14.06, "10th_percentile": 14.06, "90th_percentile": 14.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 19.11, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19.11, "10th_percentile": 19.11, "90th_percentile": 19.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 19.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19.5, "10th_percentile": 19.5, "90th_percentile": 19.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 31.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 31.2, "10th_percentile": 31.2, "90th_percentile": 31.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 26.91, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 26.91, "10th_percentile": 26.91, "90th_percentile": 26.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 8.5, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.5, "10th_percentile": 8.5, "90th_percentile": 8.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 31.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 31.2, "10th_percentile": 31.2, "90th_percentile": 31.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 39.0, "10th_percentile": 39.0, "90th_percentile": 39.0, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 39.0, "10th_percentile": 39.0, "90th_percentile": 39.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 39.0, "10th_percentile": 39.0, "90th_percentile": 39.0, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 39.0, "10th_percentile": 39.0, "90th_percentile": 39.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 39.0, "10th_percentile": 39.0, "90th_percentile": 39.0, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 39.0, "10th_percentile": 39.0, "90th_percentile": 39.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 39.0, "10th_percentile": 39.0, "90th_percentile": 39.0, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 39.0, "10th_percentile": 39.0, "90th_percentile": 39.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 39.0, "10th_percentile": 39.0, "90th_percentile": 39.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 39.0, "10th_percentile": 39.0, "90th_percentile": 39.0, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 39.0, "10th_percentile": 39.0, "90th_percentile": 39.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 35.1, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 35.1, "10th_percentile": 35.1, "90th_percentile": 35.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 25.35, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 25.35, "10th_percentile": 25.35, "90th_percentile": 25.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 19.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 19.5, "10th_percentile": 19.5, "90th_percentile": 19.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 33.15, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 33.15, "10th_percentile": 33.15, "90th_percentile": 33.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 18.49, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 18.49, "10th_percentile": 18.49, "90th_percentile": 18.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 20.55, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.55, "10th_percentile": 20.55, "90th_percentile": 20.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 39.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 39.0, "10th_percentile": 39.0, "90th_percentile": 39.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 39.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 39.0, "10th_percentile": 39.0, "90th_percentile": 39.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 25.05, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 25.05, "10th_percentile": 25.05, "90th_percentile": 25.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 24.57, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 24.57, "10th_percentile": 24.57, "90th_percentile": 24.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 29.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 29.25, "10th_percentile": 29.25, "90th_percentile": 29.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" } ] } ] }, { "description": "BUPROPION HCL 150 MG ORAL SR12", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-18386", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "00591-3541-60", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.98, "maximum": 6.0, "setting": "outpatient", "gross_charge": 6.0, "discounted_cash": 4.2, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6.0, "10th_percentile": 6.0, "90th_percentile": 6.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6.0, "10th_percentile": 6.0, "90th_percentile": 6.0, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6.0, "10th_percentile": 6.0, "90th_percentile": 6.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6.0, "10th_percentile": 6.0, "90th_percentile": 6.0, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6.0, "10th_percentile": 6.0, "90th_percentile": 6.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6.0, "10th_percentile": 6.0, "90th_percentile": 6.0, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 6.0, "10th_percentile": 6.0, "90th_percentile": 6.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 3.35, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.35, "10th_percentile": 3.35, "90th_percentile": 3.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 4.18, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.18, "10th_percentile": 4.18, "90th_percentile": 4.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1.73, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.73, "10th_percentile": 1.73, "90th_percentile": 1.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 2.16, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.16, "10th_percentile": 2.16, "90th_percentile": 2.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1.68, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.68, "10th_percentile": 1.68, "90th_percentile": 1.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1.7, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.7, "10th_percentile": 1.7, "90th_percentile": 1.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 3.72, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.72, "10th_percentile": 3.72, "90th_percentile": 3.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 5.4, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% 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; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 5.4, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% 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; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 3.9, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 3.9, "10th_percentile": 3.9, "90th_percentile": 3.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 3.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 3.0, "10th_percentile": 3.0, "90th_percentile": 3.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 4.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% 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 SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 5.1, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 5.1, "10th_percentile": 5.1, "90th_percentile": 5.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 2.94, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.94, "10th_percentile": 2.94, "90th_percentile": 2.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 1.31, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.31, "10th_percentile": 1.31, "90th_percentile": 1.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 4.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 4.8, "10th_percentile": 4.8, "90th_percentile": 4.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 6.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% 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 OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 3.16, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.16, "10th_percentile": 3.16, "90th_percentile": 3.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 2.84, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.84, "10th_percentile": 2.84, "90th_percentile": 2.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 4.14, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 4.14, "10th_percentile": 4.14, "90th_percentile": 4.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 4.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 4.8, "10th_percentile": 4.8, "90th_percentile": 4.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 3.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.0, "10th_percentile": 3.0, "90th_percentile": 3.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 3.85, "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": 3.85, "10th_percentile": 3.85, "90th_percentile": 3.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% 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 OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 3.78, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 3.78, "10th_percentile": 3.78, "90th_percentile": 3.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 4.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% 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; 75% Billed" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6.0, "10th_percentile": 6.0, "90th_percentile": 6.0, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6.0, "10th_percentile": 6.0, "90th_percentile": 6.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6.0, "10th_percentile": 6.0, "90th_percentile": 6.0, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6.0, "10th_percentile": 6.0, "90th_percentile": 6.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 3.72, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.72, "10th_percentile": 3.72, "90th_percentile": 3.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 4.07, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.07, "10th_percentile": 4.07, "90th_percentile": 4.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.98, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 0.98, "10th_percentile": 0.98, "90th_percentile": 0.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 4.18, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.18, "10th_percentile": 4.18, "90th_percentile": 4.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 2.16, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.16, "10th_percentile": 2.16, "90th_percentile": 2.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "BUPROPION HCL 150 MG ORAL SR12", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-18386", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "47335-0737-86", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.98, "maximum": 6.0, "setting": "outpatient", "gross_charge": 6.0, "discounted_cash": 4.2, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1.68, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.68, "10th_percentile": 1.68, "90th_percentile": 1.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 3.35, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.35, "10th_percentile": 3.35, "90th_percentile": 3.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 2.16, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.16, "10th_percentile": 2.16, "90th_percentile": 2.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1.7, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.7, "10th_percentile": 1.7, "90th_percentile": 1.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1.73, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.73, "10th_percentile": 1.73, "90th_percentile": 1.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 4.18, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.18, "10th_percentile": 4.18, "90th_percentile": 4.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 3.72, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.72, "10th_percentile": 3.72, "90th_percentile": 3.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 3.72, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.72, "10th_percentile": 3.72, "90th_percentile": 3.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 5.4, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% 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; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 5.4, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% 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; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 5.1, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 5.1, "10th_percentile": 5.1, "90th_percentile": 5.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 4.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% 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 SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 3.9, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 3.9, "10th_percentile": 3.9, "90th_percentile": 3.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 3.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 3.0, "10th_percentile": 3.0, "90th_percentile": 3.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.98, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 0.98, "10th_percentile": 0.98, "90th_percentile": 0.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 4.07, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.07, "10th_percentile": 4.07, "90th_percentile": 4.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 4.18, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.18, "10th_percentile": 4.18, "90th_percentile": 4.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 2.16, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.16, "10th_percentile": 2.16, "90th_percentile": 2.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 2.94, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.94, "10th_percentile": 2.94, "90th_percentile": 2.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 3.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.0, "10th_percentile": 3.0, "90th_percentile": 3.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% 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 OP Services; 100% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 4.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 4.8, "10th_percentile": 4.8, "90th_percentile": 4.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 3.16, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.16, "10th_percentile": 3.16, "90th_percentile": 3.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 2.84, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.84, "10th_percentile": 2.84, "90th_percentile": 2.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 3.78, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 3.78, "10th_percentile": 3.78, "90th_percentile": 3.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 4.14, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 4.14, "10th_percentile": 4.14, "90th_percentile": 4.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 3.85, "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": 3.85, "10th_percentile": 3.85, "90th_percentile": 3.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 4.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% 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; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 1.31, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.31, "10th_percentile": 1.31, "90th_percentile": 1.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 6.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% 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 OP Services - OON; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 4.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 4.8, "10th_percentile": 4.8, "90th_percentile": 4.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 6.0, "10th_percentile": 6.0, "90th_percentile": 6.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6.0, "10th_percentile": 6.0, "90th_percentile": 6.0, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6.0, "10th_percentile": 6.0, "90th_percentile": 6.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6.0, "10th_percentile": 6.0, "90th_percentile": 6.0, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6.0, "10th_percentile": 6.0, "90th_percentile": 6.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6.0, "10th_percentile": 6.0, "90th_percentile": 6.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6.0, "10th_percentile": 6.0, "90th_percentile": 6.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6.0, "10th_percentile": 6.0, "90th_percentile": 6.0, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6.0, "10th_percentile": 6.0, "90th_percentile": 6.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6.0, "10th_percentile": 6.0, "90th_percentile": 6.0, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6.0, "10th_percentile": 6.0, "90th_percentile": 6.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BUR CARBIDE 5.0MM DISSECT SYMMETRI 75BA50T", "code_information": [ { "code": "SUP-335593", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 347.4, "maximum": 2131.28, "setting": "outpatient", "gross_charge": 2131.28, "discounted_cash": 1491.9, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 1321.39, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1321.39, "10th_percentile": 1321.39, "90th_percentile": 1321.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 1321.39, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1321.39, "10th_percentile": 1321.39, "90th_percentile": 1321.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 614.66, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 614.66, "10th_percentile": 614.66, "90th_percentile": 614.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 1485.93, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1485.93, "10th_percentile": 1485.93, "90th_percentile": 1485.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 602.73, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 602.73, "10th_percentile": 602.73, "90th_percentile": 602.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1191.39, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1191.39, "10th_percentile": 1191.39, "90th_percentile": 1191.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 768.11, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 768.11, "10th_percentile": 768.11, "90th_percentile": 768.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 596.76, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 596.76, "10th_percentile": 596.76, "90th_percentile": 596.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 1918.15, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 1918.15, "10th_percentile": 1918.15, "90th_percentile": 1918.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 1918.15, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 1918.15, "10th_percentile": 1918.15, "90th_percentile": 1918.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 1065.64, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 1065.64, "10th_percentile": 1065.64, "90th_percentile": 1065.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 1385.33, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 1385.33, "10th_percentile": 1385.33, "90th_percentile": 1385.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 1598.46, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 1598.46, "10th_percentile": 1598.46, "90th_percentile": 1598.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 1811.59, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 1811.59, "10th_percentile": 1811.59, "90th_percentile": 1811.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 1447.14, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1447.14, "10th_percentile": 1447.14, "90th_percentile": 1447.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2131.28, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2131.28, "10th_percentile": 2131.28, "90th_percentile": 2131.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 1705.02, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 1705.02, "10th_percentile": 1705.02, "90th_percentile": 1705.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 1010.23, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1010.23, "10th_percentile": 1010.23, "90th_percentile": 1010.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 1123.18, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1123.18, "10th_percentile": 1123.18, "90th_percentile": 1123.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2131.28, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2131.28, "10th_percentile": 2131.28, "90th_percentile": 2131.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 1368.92, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1368.92, "10th_percentile": 1368.92, "90th_percentile": 1368.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 1598.46, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 1598.46, "10th_percentile": 1598.46, "90th_percentile": 1598.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 464.62, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 464.62, "10th_percentile": 464.62, "90th_percentile": 464.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1705.02, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 1705.02, "10th_percentile": 1705.02, "90th_percentile": 1705.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 1044.33, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1044.33, "10th_percentile": 1044.33, "90th_percentile": 1044.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 1065.64, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1065.64, "10th_percentile": 1065.64, "90th_percentile": 1065.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 1485.93, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1485.93, "10th_percentile": 1485.93, "90th_percentile": 1485.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 1470.58, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 1470.58, "10th_percentile": 1470.58, "90th_percentile": 1470.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 347.4, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 347.4, "10th_percentile": 347.4, "90th_percentile": 347.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 768.11, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 768.11, "10th_percentile": 768.11, "90th_percentile": 768.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 1342.71, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 1342.71, "10th_percentile": 1342.71, "90th_percentile": 1342.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 2131.28, "10th_percentile": 2131.28, "90th_percentile": 2131.28, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2131.28, "10th_percentile": 2131.28, "90th_percentile": 2131.28, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2131.28, "10th_percentile": 2131.28, "90th_percentile": 2131.28, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2131.28, "10th_percentile": 2131.28, "90th_percentile": 2131.28, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2131.28, "10th_percentile": 2131.28, "90th_percentile": 2131.28, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2131.28, "10th_percentile": 2131.28, "90th_percentile": 2131.28, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2131.28, "10th_percentile": 2131.28, "90th_percentile": 2131.28, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2131.28, "10th_percentile": 2131.28, "90th_percentile": 2131.28, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2131.28, "10th_percentile": 2131.28, "90th_percentile": 2131.28, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2131.28, "10th_percentile": 2131.28, "90th_percentile": 2131.28, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2131.28, "10th_percentile": 2131.28, "90th_percentile": 2131.28, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BUR DIAMOND 3.0MM LEGEND BALL 75BA30D", "code_information": [ { "code": "SUP-335597", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 305.31, "maximum": 1873.09, "setting": "outpatient", "gross_charge": 1873.09, "discounted_cash": 1311.16, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 529.71, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 529.71, "10th_percentile": 529.71, "90th_percentile": 529.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 524.47, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 524.47, "10th_percentile": 524.47, "90th_percentile": 524.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1047.06, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1047.06, "10th_percentile": 1047.06, "90th_percentile": 1047.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 675.06, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 675.06, "10th_percentile": 675.06, "90th_percentile": 675.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 1305.92, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1305.92, "10th_percentile": 1305.92, "90th_percentile": 1305.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 540.2, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 540.2, "10th_percentile": 540.2, "90th_percentile": 540.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 1685.78, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 1685.78, "10th_percentile": 1685.78, "90th_percentile": 1685.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 1685.78, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 1685.78, "10th_percentile": 1685.78, "90th_percentile": 1685.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1873.09, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1873.09, "10th_percentile": 1873.09, "90th_percentile": 1873.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 1404.82, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 1404.82, "10th_percentile": 1404.82, "90th_percentile": 1404.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 1203.09, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1203.09, "10th_percentile": 1203.09, "90th_percentile": 1203.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 936.55, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 936.55, "10th_percentile": 936.55, "90th_percentile": 936.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 1292.43, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 1292.43, "10th_percentile": 1292.43, "90th_percentile": 1292.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 1305.92, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1305.92, "10th_percentile": 1305.92, "90th_percentile": 1305.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH COMPSYCH", "standard_charge_dollar": 1498.47, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 1498.47, "10th_percentile": 1498.47, "90th_percentile": 1498.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 1180.05, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 1180.05, "10th_percentile": 1180.05, "90th_percentile": 1180.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 675.06, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 675.06, "10th_percentile": 675.06, "90th_percentile": 675.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 408.33, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 408.33, "10th_percentile": 408.33, "90th_percentile": 408.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 917.81, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 917.81, "10th_percentile": 917.81, "90th_percentile": 917.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1498.47, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 1498.47, "10th_percentile": 1498.47, "90th_percentile": 1498.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1873.09, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1873.09, "10th_percentile": 1873.09, "90th_percentile": 1873.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 987.12, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 987.12, "10th_percentile": 987.12, "90th_percentile": 987.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 887.84, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 887.84, "10th_percentile": 887.84, "90th_percentile": 887.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 1592.13, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 1592.13, "10th_percentile": 1592.13, "90th_percentile": 1592.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 936.55, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 936.55, "10th_percentile": 936.55, "90th_percentile": 936.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 1404.82, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 1404.82, "10th_percentile": 1404.82, "90th_percentile": 1404.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 1217.51, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 1217.51, "10th_percentile": 1217.51, "90th_percentile": 1217.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 1161.32, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1161.32, "10th_percentile": 1161.32, "90th_percentile": 1161.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 1873.09, "10th_percentile": 1873.09, "90th_percentile": 1873.09, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1873.09, "10th_percentile": 1873.09, "90th_percentile": 1873.09, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1873.09, "10th_percentile": 1873.09, "90th_percentile": 1873.09, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1873.09, "10th_percentile": 1873.09, "90th_percentile": 1873.09, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1873.09, "10th_percentile": 1873.09, "90th_percentile": 1873.09, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1873.09, "10th_percentile": 1873.09, "90th_percentile": 1873.09, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1873.09, "10th_percentile": 1873.09, "90th_percentile": 1873.09, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1873.09, "10th_percentile": 1873.09, "90th_percentile": 1873.09, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1873.09, "10th_percentile": 1873.09, "90th_percentile": 1873.09, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1873.09, "10th_percentile": 1873.09, "90th_percentile": 1873.09, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 1161.32, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1161.32, "10th_percentile": 1161.32, "90th_percentile": 1161.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 1271.83, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1271.83, "10th_percentile": 1271.83, "90th_percentile": 1271.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 305.31, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 305.31, "10th_percentile": 305.31, "90th_percentile": 305.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1873.09, "10th_percentile": 1873.09, "90th_percentile": 1873.09, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BUR EGG 4.0MM 1608-2-035", "code_information": [ { "code": "SUP-16041", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 80.68, "maximum": 494.97, "setting": "outpatient", "gross_charge": 494.97, "discounted_cash": 346.48, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 139.98, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 139.98, "10th_percentile": 139.98, "90th_percentile": 139.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 138.59, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 138.59, "10th_percentile": 138.59, "90th_percentile": 138.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 276.69, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 276.69, "10th_percentile": 276.69, "90th_percentile": 276.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 178.39, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 178.39, "10th_percentile": 178.39, "90th_percentile": 178.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 345.09, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 345.09, "10th_percentile": 345.09, "90th_percentile": 345.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 142.75, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 142.75, "10th_percentile": 142.75, "90th_percentile": 142.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 445.47, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 445.47, "10th_percentile": 445.47, "90th_percentile": 445.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 445.47, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 445.47, "10th_percentile": 445.47, "90th_percentile": 445.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 494.97, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 494.97, "10th_percentile": 494.97, "90th_percentile": 494.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 371.23, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 371.23, "10th_percentile": 371.23, "90th_percentile": 371.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 336.08, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 336.08, "10th_percentile": 336.08, "90th_percentile": 336.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH THE ALLIANCE", "standard_charge_dollar": 317.92, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 317.92, "10th_percentile": 317.92, "90th_percentile": 317.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 247.49, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 247.49, "10th_percentile": 247.49, "90th_percentile": 247.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 341.53, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 341.53, "10th_percentile": 341.53, "90th_percentile": 341.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 345.09, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 345.09, "10th_percentile": 345.09, "90th_percentile": 345.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH COMPSYCH", "standard_charge_dollar": 395.98, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 395.98, "10th_percentile": 395.98, "90th_percentile": 395.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 80.68, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 80.68, "10th_percentile": 80.68, "90th_percentile": 80.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 311.83, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 311.83, "10th_percentile": 311.83, "90th_percentile": 311.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 178.39, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 178.39, "10th_percentile": 178.39, "90th_percentile": 178.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 107.9, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 107.9, "10th_percentile": 107.9, "90th_percentile": 107.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 242.54, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 242.54, "10th_percentile": 242.54, "90th_percentile": 242.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 395.98, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 395.98, "10th_percentile": 395.98, "90th_percentile": 395.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 494.97, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 494.97, "10th_percentile": 494.97, "90th_percentile": 494.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 260.85, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 260.85, "10th_percentile": 260.85, "90th_percentile": 260.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 234.62, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 234.62, "10th_percentile": 234.62, "90th_percentile": 234.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 420.72, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 420.72, "10th_percentile": 420.72, "90th_percentile": 420.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 247.49, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 247.49, "10th_percentile": 247.49, "90th_percentile": 247.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 371.23, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 371.23, "10th_percentile": 371.23, "90th_percentile": 371.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 321.73, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 321.73, "10th_percentile": 321.73, "90th_percentile": 321.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 306.88, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 306.88, "10th_percentile": 306.88, "90th_percentile": 306.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 306.88, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 306.88, "10th_percentile": 306.88, "90th_percentile": 306.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 494.97, "10th_percentile": 494.97, "90th_percentile": 494.97, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 494.97, "10th_percentile": 494.97, "90th_percentile": 494.97, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 494.97, "10th_percentile": 494.97, "90th_percentile": 494.97, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 494.97, "10th_percentile": 494.97, "90th_percentile": 494.97, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 494.97, "10th_percentile": 494.97, "90th_percentile": 494.97, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 494.97, "10th_percentile": 494.97, "90th_percentile": 494.97, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 494.97, "10th_percentile": 494.97, "90th_percentile": 494.97, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 494.97, "10th_percentile": 494.97, "90th_percentile": 494.97, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 494.97, "10th_percentile": 494.97, "90th_percentile": 494.97, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 494.97, "10th_percentile": 494.97, "90th_percentile": 494.97, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 494.97, "10th_percentile": 494.97, "90th_percentile": 494.97, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BUR ROUTER TAPER 3MM 5407-FA3-030", "code_information": [ { "code": "SUP-370836", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 184.65, "maximum": 1132.85, "setting": "outpatient", "gross_charge": 1132.85, "discounted_cash": 792.99, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 320.37, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 320.37, "10th_percentile": 320.37, "90th_percentile": 320.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 317.2, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 317.2, "10th_percentile": 317.2, "90th_percentile": 317.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 633.26, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 633.26, "10th_percentile": 633.26, "90th_percentile": 633.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 408.28, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 408.28, "10th_percentile": 408.28, "90th_percentile": 408.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 789.82, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 789.82, "10th_percentile": 789.82, "90th_percentile": 789.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 326.71, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 326.71, "10th_percentile": 326.71, "90th_percentile": 326.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 1019.57, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 1019.57, "10th_percentile": 1019.57, "90th_percentile": 1019.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 1019.57, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 1019.57, "10th_percentile": 1019.57, "90th_percentile": 1019.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1132.85, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1132.85, "10th_percentile": 1132.85, "90th_percentile": 1132.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 849.64, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 849.64, "10th_percentile": 849.64, "90th_percentile": 849.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 769.21, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 769.21, "10th_percentile": 769.21, "90th_percentile": 769.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH THE ALLIANCE", "standard_charge_dollar": 727.63, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 727.63, "10th_percentile": 727.63, "90th_percentile": 727.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 566.43, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 566.43, "10th_percentile": 566.43, "90th_percentile": 566.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 781.67, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 781.67, "10th_percentile": 781.67, "90th_percentile": 781.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 789.82, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 789.82, "10th_percentile": 789.82, "90th_percentile": 789.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH COMPSYCH", "standard_charge_dollar": 906.28, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 906.28, "10th_percentile": 906.28, "90th_percentile": 906.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 184.65, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 184.65, "10th_percentile": 184.65, "90th_percentile": 184.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 713.7, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 713.7, "10th_percentile": 713.7, "90th_percentile": 713.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 408.28, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 408.28, "10th_percentile": 408.28, "90th_percentile": 408.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 246.96, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 246.96, "10th_percentile": 246.96, "90th_percentile": 246.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 555.1, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 555.1, "10th_percentile": 555.1, "90th_percentile": 555.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 906.28, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 906.28, "10th_percentile": 906.28, "90th_percentile": 906.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1132.85, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1132.85, "10th_percentile": 1132.85, "90th_percentile": 1132.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 597.01, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 597.01, "10th_percentile": 597.01, "90th_percentile": 597.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 536.97, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 536.97, "10th_percentile": 536.97, "90th_percentile": 536.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 962.92, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 962.92, "10th_percentile": 962.92, "90th_percentile": 962.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 566.43, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 566.43, "10th_percentile": 566.43, "90th_percentile": 566.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 849.64, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 849.64, "10th_percentile": 849.64, "90th_percentile": 849.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 736.35, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 736.35, "10th_percentile": 736.35, "90th_percentile": 736.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 702.37, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 702.37, "10th_percentile": 702.37, "90th_percentile": 702.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 702.37, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 702.37, "10th_percentile": 702.37, "90th_percentile": 702.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 1132.85, "10th_percentile": 1132.85, "90th_percentile": 1132.85, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1132.85, "10th_percentile": 1132.85, "90th_percentile": 1132.85, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1132.85, "10th_percentile": 1132.85, "90th_percentile": 1132.85, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1132.85, "10th_percentile": 1132.85, "90th_percentile": 1132.85, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1132.85, "10th_percentile": 1132.85, "90th_percentile": 1132.85, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1132.85, "10th_percentile": 1132.85, "90th_percentile": 1132.85, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1132.85, "10th_percentile": 1132.85, "90th_percentile": 1132.85, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1132.85, "10th_percentile": 1132.85, "90th_percentile": 1132.85, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1132.85, "10th_percentile": 1132.85, "90th_percentile": 1132.85, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1132.85, "10th_percentile": 1132.85, "90th_percentile": 1132.85, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1132.85, "10th_percentile": 1132.85, "90th_percentile": 1132.85, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BUR SHAVER ABRADER 5.5MM 72203127", "code_information": [ { "code": "SUP-311745", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 113.97, "maximum": 699.18, "setting": "outpatient", "gross_charge": 699.18, "discounted_cash": 489.43, "payers_information": [ { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 433.49, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 433.49, "10th_percentile": 433.49, "90th_percentile": 433.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 629.26, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 629.26, "10th_percentile": 629.26, "90th_percentile": 629.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 349.59, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 349.59, "10th_percentile": 349.59, "90th_percentile": 349.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 454.47, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 454.47, "10th_percentile": 454.47, "90th_percentile": 454.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 524.39, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 524.39, "10th_percentile": 524.39, "90th_percentile": 524.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 594.3, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 594.3, "10th_percentile": 594.3, "90th_percentile": 594.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 331.41, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 331.41, "10th_percentile": 331.41, "90th_percentile": 331.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 699.18, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 699.18, "10th_percentile": 699.18, "90th_percentile": 699.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 368.47, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 368.47, "10th_percentile": 368.47, "90th_percentile": 368.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 440.48, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 440.48, "10th_percentile": 440.48, "90th_percentile": 440.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 152.42, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 152.42, "10th_percentile": 152.42, "90th_percentile": 152.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 342.6, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 342.6, "10th_percentile": 342.6, "90th_percentile": 342.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 559.34, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 559.34, "10th_percentile": 559.34, "90th_percentile": 559.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 349.59, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 349.59, "10th_percentile": 349.59, "90th_percentile": 349.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 559.34, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 559.34, "10th_percentile": 559.34, "90th_percentile": 559.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 449.08, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 449.08, "10th_percentile": 449.08, "90th_percentile": 449.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 524.39, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 524.39, "10th_percentile": 524.39, "90th_percentile": 524.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 482.43, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 482.43, "10th_percentile": 482.43, "90th_percentile": 482.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 699.18, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 699.18, "10th_percentile": 699.18, "90th_percentile": 699.18, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 699.18, "10th_percentile": 699.18, "90th_percentile": 699.18, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 699.18, "10th_percentile": 699.18, "90th_percentile": 699.18, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 699.18, "10th_percentile": 699.18, "90th_percentile": 699.18, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 699.18, "10th_percentile": 699.18, "90th_percentile": 699.18, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 699.18, "10th_percentile": 699.18, "90th_percentile": 699.18, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 699.18, "10th_percentile": 699.18, "90th_percentile": 699.18, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 197.73, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 197.73, "10th_percentile": 197.73, "90th_percentile": 197.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 195.77, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 195.77, "10th_percentile": 195.77, "90th_percentile": 195.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 390.84, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 390.84, "10th_percentile": 390.84, "90th_percentile": 390.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 251.98, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 251.98, "10th_percentile": 251.98, "90th_percentile": 251.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 487.47, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 487.47, "10th_percentile": 487.47, "90th_percentile": 487.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 201.64, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 201.64, "10th_percentile": 201.64, "90th_percentile": 201.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 629.26, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 629.26, "10th_percentile": 629.26, "90th_percentile": 629.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 474.74, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 474.74, "10th_percentile": 474.74, "90th_percentile": 474.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 487.47, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 487.47, "10th_percentile": 487.47, "90th_percentile": 487.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 113.97, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 113.97, "10th_percentile": 113.97, "90th_percentile": 113.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 251.98, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 251.98, "10th_percentile": 251.98, "90th_percentile": 251.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 433.49, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 433.49, "10th_percentile": 433.49, "90th_percentile": 433.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 699.18, "10th_percentile": 699.18, "90th_percentile": 699.18, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 699.18, "10th_percentile": 699.18, "90th_percentile": 699.18, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 699.18, "10th_percentile": 699.18, "90th_percentile": 699.18, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 699.18, "10th_percentile": 699.18, "90th_percentile": 699.18, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 699.18, "10th_percentile": 699.18, "90th_percentile": 699.18, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BUR STRY ROUND DIA 2.0MM 1608-006-087", "code_information": [ { "code": "SUP-53468", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 140.11, "maximum": 859.6, "setting": "outpatient", "gross_charge": 859.6, "discounted_cash": 601.72, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 532.95, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 532.95, "10th_percentile": 532.95, "90th_percentile": 532.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 247.91, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 247.91, "10th_percentile": 247.91, "90th_percentile": 247.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 773.64, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 773.64, "10th_percentile": 773.64, "90th_percentile": 773.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 583.67, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 583.67, "10th_percentile": 583.67, "90th_percentile": 583.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 599.31, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 599.31, "10th_percentile": 599.31, "90th_percentile": 599.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 140.11, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 140.11, "10th_percentile": 140.11, "90th_percentile": 140.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 309.8, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 309.8, "10th_percentile": 309.8, "90th_percentile": 309.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 859.6, "10th_percentile": 859.6, "90th_percentile": 859.6, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 859.6, "10th_percentile": 859.6, "90th_percentile": 859.6, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 859.6, "10th_percentile": 859.6, "90th_percentile": 859.6, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 859.6, "10th_percentile": 859.6, "90th_percentile": 859.6, "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": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 240.69, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 240.69, "10th_percentile": 240.69, "90th_percentile": 240.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 309.8, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 309.8, "10th_percentile": 309.8, "90th_percentile": 309.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 480.52, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 480.52, "10th_percentile": 480.52, "90th_percentile": 480.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 243.09, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 243.09, "10th_percentile": 243.09, "90th_percentile": 243.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 599.31, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 599.31, "10th_percentile": 599.31, "90th_percentile": 599.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 532.95, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 532.95, "10th_percentile": 532.95, "90th_percentile": 532.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 773.64, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 773.64, "10th_percentile": 773.64, "90th_percentile": 773.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 429.8, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 429.8, "10th_percentile": 429.8, "90th_percentile": 429.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 558.74, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 558.74, "10th_percentile": 558.74, "90th_percentile": 558.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 644.7, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 644.7, "10th_percentile": 644.7, "90th_percentile": 644.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 730.66, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 730.66, "10th_percentile": 730.66, "90th_percentile": 730.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 407.45, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 407.45, "10th_percentile": 407.45, "90th_percentile": 407.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 859.6, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 859.6, "10th_percentile": 859.6, "90th_percentile": 859.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 453.01, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 453.01, "10th_percentile": 453.01, "90th_percentile": 453.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 541.55, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 541.55, "10th_percentile": 541.55, "90th_percentile": 541.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 187.39, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 187.39, "10th_percentile": 187.39, "90th_percentile": 187.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 421.2, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 421.2, "10th_percentile": 421.2, "90th_percentile": 421.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 687.68, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 687.68, "10th_percentile": 687.68, "90th_percentile": 687.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 429.8, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 429.8, "10th_percentile": 429.8, "90th_percentile": 429.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 687.68, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 687.68, "10th_percentile": 687.68, "90th_percentile": 687.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 552.12, "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": 552.12, "10th_percentile": 552.12, "90th_percentile": 552.12, "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": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 644.7, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 644.7, "10th_percentile": 644.7, "90th_percentile": 644.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 593.12, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 593.12, "10th_percentile": 593.12, "90th_percentile": 593.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 859.6, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 859.6, "10th_percentile": 859.6, "90th_percentile": 859.6, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 859.6, "10th_percentile": 859.6, "90th_percentile": 859.6, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 859.6, "10th_percentile": 859.6, "90th_percentile": 859.6, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 859.6, "10th_percentile": 859.6, "90th_percentile": 859.6, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 859.6, "10th_percentile": 859.6, "90th_percentile": 859.6, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 859.6, "10th_percentile": 859.6, "90th_percentile": 859.6, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 859.6, "10th_percentile": 859.6, "90th_percentile": 859.6, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 859.6, "10th_percentile": 859.6, "90th_percentile": 859.6, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BURR CRTCL SPHR 4MM", "code_information": [ { "code": "SUP-435505", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 584.94, "maximum": 3588.56, "setting": "outpatient", "gross_charge": 3588.56, "discounted_cash": 2511.99, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1014.84, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1014.84, "10th_percentile": 1014.84, "90th_percentile": 1014.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1004.8, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1004.8, "10th_percentile": 1004.8, "90th_percentile": 1004.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2006.01, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2006.01, "10th_percentile": 2006.01, "90th_percentile": 2006.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 1293.32, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1293.32, "10th_percentile": 1293.32, "90th_percentile": 1293.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 2501.94, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2501.94, "10th_percentile": 2501.94, "90th_percentile": 2501.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1034.94, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1034.94, "10th_percentile": 1034.94, "90th_percentile": 1034.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 3229.7, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 3229.7, "10th_percentile": 3229.7, "90th_percentile": 3229.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 3229.7, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 3229.7, "10th_percentile": 3229.7, "90th_percentile": 3229.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3588.56, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3588.56, "10th_percentile": 3588.56, "90th_percentile": 3588.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 2691.42, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 2691.42, "10th_percentile": 2691.42, "90th_percentile": 2691.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 2436.63, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2436.63, "10th_percentile": 2436.63, "90th_percentile": 2436.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH THE ALLIANCE", "standard_charge_dollar": 2304.93, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 2304.93, "10th_percentile": 2304.93, "90th_percentile": 2304.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 1794.28, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1794.28, "10th_percentile": 1794.28, "90th_percentile": 1794.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 2476.11, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 2476.11, "10th_percentile": 2476.11, "90th_percentile": 2476.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 2501.94, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2501.94, "10th_percentile": 2501.94, "90th_percentile": 2501.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH COMPSYCH", "standard_charge_dollar": 2870.85, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 2870.85, "10th_percentile": 2870.85, "90th_percentile": 2870.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 584.94, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 584.94, "10th_percentile": 584.94, "90th_percentile": 584.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 2260.79, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 2260.79, "10th_percentile": 2260.79, "90th_percentile": 2260.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 1293.32, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1293.32, "10th_percentile": 1293.32, "90th_percentile": 1293.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 782.31, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 782.31, "10th_percentile": 782.31, "90th_percentile": 782.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 1758.39, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1758.39, "10th_percentile": 1758.39, "90th_percentile": 1758.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 2870.85, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 2870.85, "10th_percentile": 2870.85, "90th_percentile": 2870.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 3588.56, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 3588.56, "10th_percentile": 3588.56, "90th_percentile": 3588.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 1891.17, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1891.17, "10th_percentile": 1891.17, "90th_percentile": 1891.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 1700.98, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1700.98, "10th_percentile": 1700.98, "90th_percentile": 1700.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 3050.28, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 3050.28, "10th_percentile": 3050.28, "90th_percentile": 3050.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 1794.28, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 1794.28, "10th_percentile": 1794.28, "90th_percentile": 1794.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 2691.42, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 2691.42, "10th_percentile": 2691.42, "90th_percentile": 2691.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 2332.56, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 2332.56, "10th_percentile": 2332.56, "90th_percentile": 2332.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 2224.91, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2224.91, "10th_percentile": 2224.91, "90th_percentile": 2224.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 2224.91, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2224.91, "10th_percentile": 2224.91, "90th_percentile": 2224.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 3588.56, "10th_percentile": 3588.56, "90th_percentile": 3588.56, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3588.56, "10th_percentile": 3588.56, "90th_percentile": 3588.56, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3588.56, "10th_percentile": 3588.56, "90th_percentile": 3588.56, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3588.56, "10th_percentile": 3588.56, "90th_percentile": 3588.56, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3588.56, "10th_percentile": 3588.56, "90th_percentile": 3588.56, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3588.56, "10th_percentile": 3588.56, "90th_percentile": 3588.56, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3588.56, "10th_percentile": 3588.56, "90th_percentile": 3588.56, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3588.56, "10th_percentile": 3588.56, "90th_percentile": 3588.56, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3588.56, "10th_percentile": 3588.56, "90th_percentile": 3588.56, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3588.56, "10th_percentile": 3588.56, "90th_percentile": 3588.56, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3588.56, "10th_percentile": 3588.56, "90th_percentile": 3588.56, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "Biopsy Salivary Gland Incisional", "code_information": [ { "code": "CASE-42405", "type": "LOCAL" }, { "code": "42405", "type": "CPT" }, { "code": "0360", "type": "RC" } ], "standard_charges": [ { "minimum": 784.0, "maximum": 3975.0, "setting": "outpatient", "gross_charge": 50970.91, "discounted_cash": 35679.64, "payers_information": [ { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.784490366; Using new claim; Scope: All Financial Classes; Cases: 1; APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $50,970.91 @ 6.8% = $3,466.02 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": 3466.02, "10th_percentile": 3466.02, "90th_percentile": 3466.02, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.784490366; Using new claim; Scope: All Financial Classes; Cases: 1; APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $50,970.91 @ 6.8% = $3,466.02 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 BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.784490366; Using new claim; Scope: All Financial Classes; Cases: 1; APCs; 100% Billed, and; Pricing Extension - NM HB XR PRC - 3M $0 RETURN & HAS APC FOR DCH & LESSOR OF; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $50,970.91 @ 12.5% = $6,371.36 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": 6371.36, "10th_percentile": 6371.36, "90th_percentile": 6371.36, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.784490366; Using new claim; Scope: All Financial Classes; Cases: 1; APCs; 100% Billed, and; Pricing Extension - NM HB XR PRC - 3M $0 RETURN & HAS APC FOR DCH & LESSOR OF; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $50,970.91 @ 12.5% = $6,371.36 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": "DCH HUMANA MEDICARE ADVT", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.784490366; Using new claim; Scope: All Financial Classes; Cases: 1; APCs; 100% Billed, and; Pricing Extension - NM HB XR PRC - 3M $0 RETURN & HAS APC FOR DCH & LESSOR OF; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $50,970.91 @ 12.5% = $6,371.36 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": 6371.36, "10th_percentile": 6371.36, "90th_percentile": 6371.36, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.784490366; Using new claim; Scope: All Financial Classes; Cases: 1; APCs; 100% Billed, and; Pricing Extension - NM HB XR PRC - 3M $0 RETURN & HAS APC FOR DCH & LESSOR OF; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $50,970.91 @ 12.5% = $6,371.36 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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_percentage": 120.0, "standard_charge_algorithm": "Re-evaluated: HLB.784490366; Using new claim; Scope: All Financial Classes; Cases: 1; APCs; 120% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 120% = $0.00. Percent of Claim Billed: $50,970.91 @ 12.5% = $6,371.36 due to $0.00 Claim Price", "median_amount": 6371.36, "10th_percentile": 6371.36, "90th_percentile": 6371.36, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.784490366; Using new claim; Scope: All Financial Classes; Cases: 1; APCs; 120% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 120% = $0.00. Percent of Claim Billed: $50,970.91 @ 12.5% = $6,371.36 due to $0.00 Claim Price" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_percentage": 93.0, "standard_charge_algorithm": "Re-evaluated: HLB.784490366; Using new claim; Scope: All Financial Classes; Cases: 1; APCs; 93% Billed, and; Pricing Extension - NM HB XR PRC - 3M $0 RETURN & HAS APC FOR DCH & LESSOR OF; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 93% = $0.00. Percent of Claim Billed: $50,970.91 @ 12.5% = $6,371.36 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": 6371.36, "10th_percentile": 6371.36, "90th_percentile": 6371.36, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.784490366; Using new claim; Scope: All Financial Classes; Cases: 1; APCs; 93% Billed, and; Pricing Extension - NM HB XR PRC - 3M $0 RETURN & HAS APC FOR DCH & LESSOR OF; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 93% = $0.00. Percent of Claim Billed: $50,970.91 @ 12.5% = $6,371.36 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 BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_percentage": 88.91, "standard_charge_algorithm": "Additional drugs and supplies can be included in reimbursement.", "median_amount": 2719.0, "10th_percentile": 2719.0, "90th_percentile": 2719.0, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_percentage": 88.91, "standard_charge_algorithm": "Additional drugs and supplies can be included in reimbursement.", "median_amount": 2719.0, "10th_percentile": 2719.0, "90th_percentile": 2719.0, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_percentage": 16.3, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 8308.26, "10th_percentile": 8308.26, "90th_percentile": 8308.26, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_percentage": 33.4, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 17024.27, "10th_percentile": 17024.27, "90th_percentile": 17024.27, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_percentage": 90.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 45873.86, "10th_percentile": 45873.86, "90th_percentile": 45873.86, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_percentage": 28.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 14271.86, "10th_percentile": 14271.86, "90th_percentile": 14271.86, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_percentage": 28.9, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 14730.6, "10th_percentile": 14730.6, "90th_percentile": 14730.6, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_percentage": 28.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 14271.86, "10th_percentile": 14271.86, "90th_percentile": 14271.86, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_percentage": 55.9, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 28492.74, "10th_percentile": 28492.74, "90th_percentile": 28492.74, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_percentage": 33.4, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 17024.27, "10th_percentile": 17024.27, "90th_percentile": 17024.27, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 25485.5, "10th_percentile": 25485.5, "90th_percentile": 25485.5, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_percentage": 37.5, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 16461.5, "10th_percentile": 16461.5, "90th_percentile": 16461.5, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 784.0, "standard_charge_algorithm": "Re-evaluated: HLB.784490366; Using new claim; Scope: All Financial Classes; Cases: 1; Amb Surgery Group 2; Case Rate @ $784.00, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3948.0, "10th_percentile": 3948.0, "90th_percentile": 3948.0, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 862.5, "standard_charge_algorithm": "Re-evaluated: HLB.784490366; Using new claim; Scope: All Financial Classes; Cases: 1; Amb Surgery Group 2; Case Rate @ $862.50, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4343.5, "10th_percentile": 4343.5, "90th_percentile": 4343.5, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_percentage": 120.0, "standard_charge_algorithm": "Re-evaluated: HLB.784490366; Using new claim; Scope: All Financial Classes; Cases: 1; APCs; 120% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 120% = $0.00. Percent of Claim Billed: $50,970.91 @ 12.5% = $6,371.36 due to $0.00 Claim Price", "median_amount": 6371.36, "10th_percentile": 6371.36, "90th_percentile": 6371.36, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.784490366; Using new claim; Scope: All Financial Classes; Cases: 1; APCs; 120% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 120% = $0.00. Percent of Claim Billed: $50,970.91 @ 12.5% = $6,371.36 due to $0.00 Claim Price" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.784490366; Using new claim; Scope: All Financial Classes; Cases: 1; APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $50,970.91 @ 12.5% = $6,371.36 due to $0.00 Claim Price", "median_amount": 6371.36, "10th_percentile": 6371.36, "90th_percentile": 6371.36, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.784490366; Using new claim; Scope: All Financial Classes; Cases: 1; APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $50,970.91 @ 12.5% = $6,371.36 due to $0.00 Claim Price" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.784490366; Using new claim; Scope: All Financial Classes; Cases: 1; APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $50,970.91 @ 12.5% = $6,371.36 due to $0.00 Claim Price", "median_amount": 6371.36, "10th_percentile": 6371.36, "90th_percentile": 6371.36, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.784490366; Using new claim; Scope: All Financial Classes; Cases: 1; APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $50,970.91 @ 12.5% = $6,371.36 due to $0.00 Claim Price" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.784490366; Using new claim; Scope: All Financial Classes; Cases: 1; APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $50,970.91 @ 6.8% = $3,466.02 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": 3466.02, "10th_percentile": 3466.02, "90th_percentile": 3466.02, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.784490366; Using new claim; Scope: All Financial Classes; Cases: 1; APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $50,970.91 @ 6.8% = $3,466.02 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": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.784490366; Using new claim; Scope: All Financial Classes; Cases: 1; APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $50,970.91 @ 6.8% = $3,466.02 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": 3466.02, "10th_percentile": 3466.02, "90th_percentile": 3466.02, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.784490366; Using new claim; Scope: All Financial Classes; Cases: 1; APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $50,970.91 @ 6.8% = $3,466.02 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": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 40776.73, "10th_percentile": 40776.73, "90th_percentile": 40776.73, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_percentage": 75.2, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 32969.15, "10th_percentile": 32969.15, "90th_percentile": 32969.15, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 40776.73, "10th_percentile": 40776.73, "90th_percentile": 40776.73, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 35169.94, "10th_percentile": 35169.94, "90th_percentile": 35169.94, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 38228.19, "10th_percentile": 38228.19, "90th_percentile": 38228.19, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 25485.5, "10th_percentile": 25485.5, "90th_percentile": 25485.5, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_percentage": 65.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 33131.11, "10th_percentile": 33131.11, "90th_percentile": 33131.11, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_percentage": 85.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 43325.28, "10th_percentile": 43325.28, "90th_percentile": 43325.28, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 32111.69, "10th_percentile": 32111.69, "90th_percentile": 32111.69, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_percentage": 90.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 45873.86, "10th_percentile": 45873.86, "90th_percentile": 45873.86, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 50970.91, "10th_percentile": 50970.91, "90th_percentile": 50970.91, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 38228.19, "10th_percentile": 38228.19, "90th_percentile": 38228.19, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_percentage": 64.23, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 31752.6, "10th_percentile": 31752.6, "90th_percentile": 31752.6, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 50970.91, "10th_percentile": 50970.91, "90th_percentile": 50970.91, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 3577.0, "standard_charge_algorithm": "Re-evaluated: HLB.784490366; Using new claim; Scope: All Financial Classes; Cases: 1; OP Surgery Group 3; Case Rate @ $3,577.00, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4691.77, "10th_percentile": 4691.77, "90th_percentile": 4691.77, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 3975.0, "standard_charge_algorithm": "Re-evaluated: HLB.784490366; Using new claim; Scope: All Financial Classes; Cases: 1; OP Surgery Group 3; Case Rate @ $3,975.00, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5208.27, "10th_percentile": 5208.27, "90th_percentile": 5208.27, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 784.0, "standard_charge_algorithm": "Re-evaluated: HLB.784490366; Using new claim; Scope: All Financial Classes; Cases: 1; Amb Surgery Group 2; Case Rate @ $784.00, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3948.0, "10th_percentile": 3948.0, "90th_percentile": 3948.0, "count": "1 through 10", "methodology": "case rate" } ] } ] }, { "description": "CABAZITAXEL 10 MG/ML (FIRST DILUTION) IV SOLN", "drug_information": { "unit": 6.0, "type": "ML" }, "code_information": [ { "code": "RX-183803", "type": "CDM" }, { "code": "J9043", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "00024-5824-11", "type": "NDC" } ], "standard_charges": [ { "minimum": 43130.69, "maximum": 289467.75, "setting": "outpatient", "gross_charge": 289467.75, "discounted_cash": 202627.42, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 289467.75, "10th_percentile": 289467.75, "90th_percentile": 289467.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 289467.75, "10th_percentile": 289467.75, "90th_percentile": 289467.75, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 289467.75, "10th_percentile": 289467.75, "90th_percentile": 289467.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $289,467.75 @ 6.8% = $19,683.81 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": 19683.81, "10th_percentile": 19683.81, "90th_percentile": 19683.81, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $289,467.75 @ 6.8% = $19,683.81 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 BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 67445.99, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 67445.99, "10th_percentile": 67445.99, "90th_percentile": 67445.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 67445.99, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 67445.99, "10th_percentile": 67445.99, "90th_percentile": 67445.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 43130.69, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 43130.69, "10th_percentile": 43130.69, "90th_percentile": 43130.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 43130.69, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 43130.69, "10th_percentile": 43130.69, "90th_percentile": 43130.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 201816.92, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 201816.92, "10th_percentile": 201816.92, "90th_percentile": 201816.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 201816.92, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 201816.92, "10th_percentile": 201816.92, "90th_percentile": 201816.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 260520.98, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 260520.98, "10th_percentile": 260520.98, "90th_percentile": 260520.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 144733.88, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 144733.88, "10th_percentile": 144733.88, "90th_percentile": 144733.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 231574.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 231574.2, "10th_percentile": 231574.2, "90th_percentile": 231574.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 161812.47, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 161812.47, "10th_percentile": 161812.47, "90th_percentile": 161812.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 47183.24, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 47183.24, "10th_percentile": 47183.24, "90th_percentile": 47183.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 52104.2, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 52104.2, "10th_percentile": 52104.2, "90th_percentile": 52104.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 349.55, "10th_percentile": 349.55, "90th_percentile": 349.55, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 289467.75, "10th_percentile": 289467.75, "90th_percentile": 289467.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 289467.75, "10th_percentile": 289467.75, "90th_percentile": 289467.75, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 289467.75, "10th_percentile": 289467.75, "90th_percentile": 289467.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $289,467.75 @ 12.5% = $36,183.47 due to $0.00 Claim Price", "median_amount": 36183.47, "10th_percentile": 36183.47, "90th_percentile": 36183.47, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $289,467.75 @ 12.5% = $36,183.47 due to $0.00 Claim Price" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $289,467.75 @ 6.8% = $19,683.81 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": 19683.81, "10th_percentile": 19683.81, "90th_percentile": 19683.81, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $289,467.75 @ 6.8% = $19,683.81 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $289,467.75 @ 6.8% = $19,683.81 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": 19683.81, "10th_percentile": 19683.81, "90th_percentile": 19683.81, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $289,467.75 @ 6.8% = $19,683.81 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": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 260520.98, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 260520.98, "10th_percentile": 260520.98, "90th_percentile": 260520.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 188154.05, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 188154.05, "10th_percentile": 188154.05, "90th_percentile": 188154.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 217100.81, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 217100.81, "10th_percentile": 217100.81, "90th_percentile": 217100.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 144733.88, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 144733.88, "10th_percentile": 144733.88, "90th_percentile": 144733.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 246047.6, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 246047.6, "10th_percentile": 246047.6, "90th_percentile": 246047.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 199732.75, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 199732.75, "10th_percentile": 199732.75, "90th_percentile": 199732.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 217100.81, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 217100.81, "10th_percentile": 217100.81, "90th_percentile": 217100.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 182364.69, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 182364.69, "10th_percentile": 182364.69, "90th_percentile": 182364.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 231574.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 231574.2, "10th_percentile": 231574.2, "90th_percentile": 231574.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 289467.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 289467.75, "10th_percentile": 289467.75, "90th_percentile": 289467.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 289467.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 289467.75, "10th_percentile": 289467.75, "90th_percentile": 289467.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) IV SOLN", "drug_information": { "unit": 3.0, "type": "ML" }, "code_information": [ { "code": "RX-77412", "type": "CDM" }, { "code": "J0706", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "47335-0289-40", "type": "NDC" } ], "standard_charges": [ { "minimum": 16.32, "maximum": 109.5, "setting": "outpatient", "gross_charge": 109.5, "discounted_cash": 76.65, "payers_information": [ { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 109.5, "10th_percentile": 109.5, "90th_percentile": 109.5, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 109.5, "10th_percentile": 109.5, "90th_percentile": 109.5, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 109.5, "10th_percentile": 109.5, "90th_percentile": 109.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 109.5, "10th_percentile": 109.5, "90th_percentile": 109.5, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 109.5, "10th_percentile": 109.5, "90th_percentile": 109.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 109.5, "10th_percentile": 109.5, "90th_percentile": 109.5, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 109.5, "10th_percentile": 109.5, "90th_percentile": 109.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $109.50 @ 12.5% = $13.69 due to $0.00 Claim Price", "median_amount": 13.69, "10th_percentile": 13.69, "90th_percentile": 13.69, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $109.50 @ 12.5% = $13.69 due to $0.00 Claim Price" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $109.50 @ 6.8% = $7.45 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": 7.45, "10th_percentile": 7.45, "90th_percentile": 7.45, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $109.50 @ 6.8% = $7.45 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $109.50 @ 6.8% = $7.45 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": 7.45, "10th_percentile": 7.45, "90th_percentile": 7.45, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $109.50 @ 6.8% = $7.45 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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $109.50 @ 6.8% = $7.45 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": 7.45, "10th_percentile": 7.45, "90th_percentile": 7.45, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $109.50 @ 6.8% = $7.45 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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 25.51, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 25.51, "10th_percentile": 25.51, "90th_percentile": 25.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 19.71, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19.71, "10th_percentile": 19.71, "90th_percentile": 19.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 61.21, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 61.21, "10th_percentile": 61.21, "90th_percentile": 61.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 76.34, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 76.34, "10th_percentile": 76.34, "90th_percentile": 76.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 16.32, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.32, "10th_percentile": 16.32, "90th_percentile": 16.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 16.32, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.32, "10th_percentile": 16.32, "90th_percentile": 16.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 98.55, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 98.55, "10th_percentile": 98.55, "90th_percentile": 98.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 98.55, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 98.55, "10th_percentile": 98.55, "90th_percentile": 98.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 71.18, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 71.18, "10th_percentile": 71.18, "90th_percentile": 71.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 82.13, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 82.13, "10th_percentile": 82.13, "90th_percentile": 82.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 54.75, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 54.75, "10th_percentile": 54.75, "90th_percentile": 54.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 93.08, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 93.08, "10th_percentile": 93.08, "90th_percentile": 93.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 76.34, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 76.34, "10th_percentile": 76.34, "90th_percentile": 76.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 75.56, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 75.56, "10th_percentile": 75.56, "90th_percentile": 75.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 87.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 87.6, "10th_percentile": 87.6, "90th_percentile": 87.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 54.75, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 54.75, "10th_percentile": 54.75, "90th_percentile": 54.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 82.13, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 82.13, "10th_percentile": 82.13, "90th_percentile": 82.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 68.99, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 68.99, "10th_percentile": 68.99, "90th_percentile": 68.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 87.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 87.6, "10th_percentile": 87.6, "90th_percentile": 87.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 17.85, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 17.85, "10th_percentile": 17.85, "90th_percentile": 17.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 109.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 109.5, "10th_percentile": 109.5, "90th_percentile": 109.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 25.51, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 25.51, "10th_percentile": 25.51, "90th_percentile": 25.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 109.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 109.5, "10th_percentile": 109.5, "90th_percentile": 109.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 70.33, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 70.33, "10th_percentile": 70.33, "90th_percentile": 70.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." } ] } ] }, { "description": "CALCIUM CARBONATE-VITAMIN D3 500 MG-5 MCG (200 UNIT) ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-19483", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "00904-5460-52", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.16, "maximum": 1.0, "setting": "outpatient", "gross_charge": 1.0, "discounted_cash": 0.7, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "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": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "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": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "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 BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS 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": "DCH 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" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH 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": "DCH 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": "GLOBAL EXCEL [1712]", "plan_name": "DCH 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": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "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 BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.28, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.28, "10th_percentile": 0.28, "90th_percentile": 0.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.29, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.29, "10th_percentile": 0.29, "90th_percentile": 0.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 0.36, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.36, "10th_percentile": 0.36, "90th_percentile": 0.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 0.56, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.56, "10th_percentile": 0.56, "90th_percentile": 0.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 0.7, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.7, "10th_percentile": 0.7, "90th_percentile": 0.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.28, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.28, "10th_percentile": 0.28, "90th_percentile": 0.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 0.62, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 0.62, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 0.9, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 0.9, "10th_percentile": 0.9, "90th_percentile": 0.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 0.9, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 0.9, "10th_percentile": 0.9, "90th_percentile": 0.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 0.75, "10th_percentile": 0.75, "90th_percentile": 0.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 0.65, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 0.65, "10th_percentile": 0.65, "90th_percentile": 0.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 0.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 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 SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 0.85, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 0.85, "10th_percentile": 0.85, "90th_percentile": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 0.47, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.47, "10th_percentile": 0.47, "90th_percentile": 0.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 0.53, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.53, "10th_percentile": 0.53, "90th_percentile": 0.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH 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": "MULTIPLAN/PHCS [142]", "plan_name": "DCH 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": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 0.68, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.68, "10th_percentile": 0.68, "90th_percentile": 0.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.16, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 0.16, "10th_percentile": 0.16, "90th_percentile": 0.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 0.22, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.22, "10th_percentile": 0.22, "90th_percentile": 0.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 0.49, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.49, "10th_percentile": 0.49, "90th_percentile": 0.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH 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": "THE ALLIANCE [1703]", "plan_name": "DCH 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": "HEALTHLINK [125]", "plan_name": "DCH 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": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 0.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 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 DEF; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 0.69, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 0.69, "10th_percentile": 0.69, "90th_percentile": 0.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 0.75, "10th_percentile": 0.75, "90th_percentile": 0.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 0.7, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.7, "10th_percentile": 0.7, "90th_percentile": 0.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 0.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.5, "10th_percentile": 0.5, "90th_percentile": 0.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 0.36, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.36, "10th_percentile": 0.36, "90th_percentile": 0.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual 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": "DCH ILLINOIS MEDICAID", "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": "CANNISTER DRAINAGE WOUND INFOVAC 500ML W/GEL 5/CS M82750635S", "code_information": [ { "code": "SUP-316051", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 59.48, "maximum": 364.91, "setting": "outpatient", "gross_charge": 364.91, "discounted_cash": 255.44, "payers_information": [ { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 226.24, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 226.24, "10th_percentile": 226.24, "90th_percentile": 226.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 328.42, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 328.42, "10th_percentile": 328.42, "90th_percentile": 328.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 182.46, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 182.46, "10th_percentile": 182.46, "90th_percentile": 182.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 237.19, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 237.19, "10th_percentile": 237.19, "90th_percentile": 237.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 273.68, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 273.68, "10th_percentile": 273.68, "90th_percentile": 273.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 310.17, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 310.17, "10th_percentile": 310.17, "90th_percentile": 310.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 364.91, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 364.91, "10th_percentile": 364.91, "90th_percentile": 364.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 291.93, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 291.93, "10th_percentile": 291.93, "90th_percentile": 291.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 172.97, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 172.97, "10th_percentile": 172.97, "90th_percentile": 172.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 192.31, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 192.31, "10th_percentile": 192.31, "90th_percentile": 192.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 364.91, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 364.91, "10th_percentile": 364.91, "90th_percentile": 364.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 234.38, "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": 234.38, "10th_percentile": 234.38, "90th_percentile": 234.38, "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": "DCH PHCS", "standard_charge_dollar": 273.68, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 273.68, "10th_percentile": 273.68, "90th_percentile": 273.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 79.55, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 79.55, "10th_percentile": 79.55, "90th_percentile": 79.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 291.93, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 291.93, "10th_percentile": 291.93, "90th_percentile": 291.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 178.81, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 178.81, "10th_percentile": 178.81, "90th_percentile": 178.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 182.46, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 182.46, "10th_percentile": 182.46, "90th_percentile": 182.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 251.79, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 251.79, "10th_percentile": 251.79, "90th_percentile": 251.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 229.89, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 229.89, "10th_percentile": 229.89, "90th_percentile": 229.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 364.91, "10th_percentile": 364.91, "90th_percentile": 364.91, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 364.91, "10th_percentile": 364.91, "90th_percentile": 364.91, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 364.91, "10th_percentile": 364.91, "90th_percentile": 364.91, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 364.91, "10th_percentile": 364.91, "90th_percentile": 364.91, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 364.91, "10th_percentile": 364.91, "90th_percentile": 364.91, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 364.91, "10th_percentile": 364.91, "90th_percentile": 364.91, "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": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 103.2, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 103.2, "10th_percentile": 103.2, "90th_percentile": 103.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 102.17, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 102.17, "10th_percentile": 102.17, "90th_percentile": 102.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 203.98, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 203.98, "10th_percentile": 203.98, "90th_percentile": 203.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 131.51, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 131.51, "10th_percentile": 131.51, "90th_percentile": 131.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 254.42, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 254.42, "10th_percentile": 254.42, "90th_percentile": 254.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 105.24, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 105.24, "10th_percentile": 105.24, "90th_percentile": 105.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 328.42, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 328.42, "10th_percentile": 328.42, "90th_percentile": 328.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 247.77, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 247.77, "10th_percentile": 247.77, "90th_percentile": 247.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 254.42, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 254.42, "10th_percentile": 254.42, "90th_percentile": 254.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 59.48, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 59.48, "10th_percentile": 59.48, "90th_percentile": 59.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 131.51, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 131.51, "10th_percentile": 131.51, "90th_percentile": 131.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 226.24, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 226.24, "10th_percentile": 226.24, "90th_percentile": 226.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 364.91, "10th_percentile": 364.91, "90th_percentile": 364.91, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 364.91, "10th_percentile": 364.91, "90th_percentile": 364.91, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 364.91, "10th_percentile": 364.91, "90th_percentile": 364.91, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 364.91, "10th_percentile": 364.91, "90th_percentile": 364.91, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 364.91, "10th_percentile": 364.91, "90th_percentile": 364.91, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "CANNULA CRYSTAL SMOOTH 5.75X7CM AR-6562", "code_information": [ { "code": "SUP-55041", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 41.72, "maximum": 255.98, "setting": "outpatient", "gross_charge": 255.98, "discounted_cash": 179.19, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 73.82, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 73.82, "10th_percentile": 73.82, "90th_percentile": 73.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 71.67, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 71.67, "10th_percentile": 71.67, "90th_percentile": 71.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 92.26, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 92.26, "10th_percentile": 92.26, "90th_percentile": 92.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 143.09, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 143.09, "10th_percentile": 143.09, "90th_percentile": 143.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 72.39, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 72.39, "10th_percentile": 72.39, "90th_percentile": 72.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 178.47, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 178.47, "10th_percentile": 178.47, "90th_percentile": 178.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 158.71, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 158.71, "10th_percentile": 158.71, "90th_percentile": 158.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 158.71, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 158.71, "10th_percentile": 158.71, "90th_percentile": 158.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 230.38, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 230.38, "10th_percentile": 230.38, "90th_percentile": 230.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 230.38, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 230.38, "10th_percentile": 230.38, "90th_percentile": 230.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 127.99, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 127.99, "10th_percentile": 127.99, "90th_percentile": 127.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 166.39, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 166.39, "10th_percentile": 166.39, "90th_percentile": 166.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 191.99, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 191.99, "10th_percentile": 191.99, "90th_percentile": 191.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 217.58, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 217.58, "10th_percentile": 217.58, "90th_percentile": 217.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 92.26, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 92.26, "10th_percentile": 92.26, "90th_percentile": 92.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 121.33, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 121.33, "10th_percentile": 121.33, "90th_percentile": 121.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 255.98, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 255.98, "10th_percentile": 255.98, "90th_percentile": 255.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 134.9, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 134.9, "10th_percentile": 134.9, "90th_percentile": 134.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 161.27, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 161.27, "10th_percentile": 161.27, "90th_percentile": 161.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 55.8, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 55.8, "10th_percentile": 55.8, "90th_percentile": 55.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 125.43, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 125.43, "10th_percentile": 125.43, "90th_percentile": 125.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 204.78, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 204.78, "10th_percentile": 204.78, "90th_percentile": 204.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 127.99, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 127.99, "10th_percentile": 127.99, "90th_percentile": 127.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 41.72, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 41.72, "10th_percentile": 41.72, "90th_percentile": 41.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 204.78, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 204.78, "10th_percentile": 204.78, "90th_percentile": 204.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 164.42, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 164.42, "10th_percentile": 164.42, "90th_percentile": 164.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 191.99, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 191.99, "10th_percentile": 191.99, "90th_percentile": 191.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 178.47, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 178.47, "10th_percentile": 178.47, "90th_percentile": 178.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 176.63, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 176.63, "10th_percentile": 176.63, "90th_percentile": 176.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 173.81, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 173.81, "10th_percentile": 173.81, "90th_percentile": 173.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 255.98, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 255.98, "10th_percentile": 255.98, "90th_percentile": 255.98, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 255.98, "10th_percentile": 255.98, "90th_percentile": 255.98, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 255.98, "10th_percentile": 255.98, "90th_percentile": 255.98, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 255.98, "10th_percentile": 255.98, "90th_percentile": 255.98, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 255.98, "10th_percentile": 255.98, "90th_percentile": 255.98, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 255.98, "10th_percentile": 255.98, "90th_percentile": 255.98, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 255.98, "10th_percentile": 255.98, "90th_percentile": 255.98, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 255.98, "10th_percentile": 255.98, "90th_percentile": 255.98, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 255.98, "10th_percentile": 255.98, "90th_percentile": 255.98, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 255.98, "10th_percentile": 255.98, "90th_percentile": 255.98, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 255.98, "10th_percentile": 255.98, "90th_percentile": 255.98, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 255.98, "10th_percentile": 255.98, "90th_percentile": 255.98, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "CANNULA OPTH 11MM 27GA ANG AC NDL 8065441720", "code_information": [ { "code": "SUP-413560", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 22.18, "maximum": 136.1, "setting": "outpatient", "gross_charge": 136.1, "discounted_cash": 95.27, "payers_information": [ { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 84.38, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 84.38, "10th_percentile": 84.38, "90th_percentile": 84.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 122.49, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 122.49, "10th_percentile": 122.49, "90th_percentile": 122.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 68.05, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 68.05, "10th_percentile": 68.05, "90th_percentile": 68.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 88.47, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 88.47, "10th_percentile": 88.47, "90th_percentile": 88.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 102.08, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 102.08, "10th_percentile": 102.08, "90th_percentile": 102.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 115.69, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 115.69, "10th_percentile": 115.69, "90th_percentile": 115.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 136.1, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 136.1, "10th_percentile": 136.1, "90th_percentile": 136.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 108.88, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 108.88, "10th_percentile": 108.88, "90th_percentile": 108.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 64.51, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 64.51, "10th_percentile": 64.51, "90th_percentile": 64.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 71.72, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 71.72, "10th_percentile": 71.72, "90th_percentile": 71.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 136.1, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 136.1, "10th_percentile": 136.1, "90th_percentile": 136.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 87.42, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 87.42, "10th_percentile": 87.42, "90th_percentile": 87.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 102.08, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 102.08, "10th_percentile": 102.08, "90th_percentile": 102.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 108.88, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 108.88, "10th_percentile": 108.88, "90th_percentile": 108.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 66.69, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 66.69, "10th_percentile": 66.69, "90th_percentile": 66.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 93.91, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 93.91, "10th_percentile": 93.91, "90th_percentile": 93.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 85.74, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 85.74, "10th_percentile": 85.74, "90th_percentile": 85.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 136.1, "10th_percentile": 136.1, "90th_percentile": 136.1, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 136.1, "10th_percentile": 136.1, "90th_percentile": 136.1, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 136.1, "10th_percentile": 136.1, "90th_percentile": 136.1, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 136.1, "10th_percentile": 136.1, "90th_percentile": 136.1, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 136.1, "10th_percentile": 136.1, "90th_percentile": 136.1, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 136.1, "10th_percentile": 136.1, "90th_percentile": 136.1, "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": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 38.49, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 38.49, "10th_percentile": 38.49, "90th_percentile": 38.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 38.11, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 38.11, "10th_percentile": 38.11, "90th_percentile": 38.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 76.08, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 76.08, "10th_percentile": 76.08, "90th_percentile": 76.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 49.05, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 49.05, "10th_percentile": 49.05, "90th_percentile": 49.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 94.89, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 94.89, "10th_percentile": 94.89, "90th_percentile": 94.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 39.25, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 39.25, "10th_percentile": 39.25, "90th_percentile": 39.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 122.49, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 122.49, "10th_percentile": 122.49, "90th_percentile": 122.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 92.41, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 92.41, "10th_percentile": 92.41, "90th_percentile": 92.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 68.05, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 68.05, "10th_percentile": 68.05, "90th_percentile": 68.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 94.89, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 94.89, "10th_percentile": 94.89, "90th_percentile": 94.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 22.18, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 22.18, "10th_percentile": 22.18, "90th_percentile": 22.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 49.05, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 49.05, "10th_percentile": 49.05, "90th_percentile": 49.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 29.67, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 29.67, "10th_percentile": 29.67, "90th_percentile": 29.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 84.38, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 84.38, "10th_percentile": 84.38, "90th_percentile": 84.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 136.1, "10th_percentile": 136.1, "90th_percentile": 136.1, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 136.1, "10th_percentile": 136.1, "90th_percentile": 136.1, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 136.1, "10th_percentile": 136.1, "90th_percentile": 136.1, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 136.1, "10th_percentile": 136.1, "90th_percentile": 136.1, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 136.1, "10th_percentile": 136.1, "90th_percentile": 136.1, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "CANNULA THREADED 8.25X7CM AR-6530", "code_information": [ { "code": "SUP-9054341", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 45.89, "maximum": 281.55, "setting": "outpatient", "gross_charge": 281.55, "discounted_cash": 197.08, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 174.56, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 174.56, "10th_percentile": 174.56, "90th_percentile": 174.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 191.17, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 191.17, "10th_percentile": 191.17, "90th_percentile": 191.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 196.3, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 196.3, "10th_percentile": 196.3, "90th_percentile": 196.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 45.89, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 45.89, "10th_percentile": 45.89, "90th_percentile": 45.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 101.47, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 101.47, "10th_percentile": 101.47, "90th_percentile": 101.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 281.55, "10th_percentile": 281.55, "90th_percentile": 281.55, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 281.55, "10th_percentile": 281.55, "90th_percentile": 281.55, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 281.55, "10th_percentile": 281.55, "90th_percentile": 281.55, "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": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 79.62, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 79.62, "10th_percentile": 79.62, "90th_percentile": 79.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 78.83, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 78.83, "10th_percentile": 78.83, "90th_percentile": 78.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 157.39, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 157.39, "10th_percentile": 157.39, "90th_percentile": 157.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 101.47, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 101.47, "10th_percentile": 101.47, "90th_percentile": 101.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 196.3, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 196.3, "10th_percentile": 196.3, "90th_percentile": 196.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 81.2, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 81.2, "10th_percentile": 81.2, "90th_percentile": 81.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 253.4, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 253.4, "10th_percentile": 253.4, "90th_percentile": 253.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 253.4, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 253.4, "10th_percentile": 253.4, "90th_percentile": 253.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 281.55, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 281.55, "10th_percentile": 281.55, "90th_percentile": 281.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 211.16, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 211.16, "10th_percentile": 211.16, "90th_percentile": 211.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 180.84, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 180.84, "10th_percentile": 180.84, "90th_percentile": 180.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 140.78, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 140.78, "10th_percentile": 140.78, "90th_percentile": 140.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 194.27, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 194.27, "10th_percentile": 194.27, "90th_percentile": 194.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 225.24, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 225.24, "10th_percentile": 225.24, "90th_percentile": 225.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 177.38, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 177.38, "10th_percentile": 177.38, "90th_percentile": 177.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 61.38, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 61.38, "10th_percentile": 61.38, "90th_percentile": 61.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 137.96, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 137.96, "10th_percentile": 137.96, "90th_percentile": 137.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 225.24, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 225.24, "10th_percentile": 225.24, "90th_percentile": 225.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 281.55, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 281.55, "10th_percentile": 281.55, "90th_percentile": 281.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 148.38, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 148.38, "10th_percentile": 148.38, "90th_percentile": 148.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 133.45, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 133.45, "10th_percentile": 133.45, "90th_percentile": 133.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 239.32, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 239.32, "10th_percentile": 239.32, "90th_percentile": 239.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 140.78, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 140.78, "10th_percentile": 140.78, "90th_percentile": 140.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 211.16, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 211.16, "10th_percentile": 211.16, "90th_percentile": 211.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 183.01, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 183.01, "10th_percentile": 183.01, "90th_percentile": 183.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 174.56, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 174.56, "10th_percentile": 174.56, "90th_percentile": 174.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 281.55, "10th_percentile": 281.55, "90th_percentile": 281.55, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 281.55, "10th_percentile": 281.55, "90th_percentile": 281.55, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 281.55, "10th_percentile": 281.55, "90th_percentile": 281.55, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 281.55, "10th_percentile": 281.55, "90th_percentile": 281.55, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 281.55, "10th_percentile": 281.55, "90th_percentile": 281.55, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 281.55, "10th_percentile": 281.55, "90th_percentile": 281.55, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 281.55, "10th_percentile": 281.55, "90th_percentile": 281.55, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 281.55, "10th_percentile": 281.55, "90th_percentile": 281.55, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "CANNULA THREADED CLEAR 5.5X75MM 214108", "code_information": [ { "code": "SUP-335589", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 55.06, "maximum": 337.82, "setting": "outpatient", "gross_charge": 337.82, "discounted_cash": 236.47, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 95.54, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 95.54, "10th_percentile": 95.54, "90th_percentile": 95.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 94.59, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 94.59, "10th_percentile": 94.59, "90th_percentile": 94.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 188.84, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 188.84, "10th_percentile": 188.84, "90th_percentile": 188.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 121.75, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 121.75, "10th_percentile": 121.75, "90th_percentile": 121.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 235.53, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 235.53, "10th_percentile": 235.53, "90th_percentile": 235.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 97.43, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 97.43, "10th_percentile": 97.43, "90th_percentile": 97.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 304.04, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 304.04, "10th_percentile": 304.04, "90th_percentile": 304.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 304.04, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 304.04, "10th_percentile": 304.04, "90th_percentile": 304.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 337.82, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 337.82, "10th_percentile": 337.82, "90th_percentile": 337.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 253.37, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 253.37, "10th_percentile": 253.37, "90th_percentile": 253.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 229.38, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 229.38, "10th_percentile": 229.38, "90th_percentile": 229.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH THE ALLIANCE", "standard_charge_dollar": 216.98, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 216.98, "10th_percentile": 216.98, "90th_percentile": 216.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 168.91, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 168.91, "10th_percentile": 168.91, "90th_percentile": 168.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 233.1, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 233.1, "10th_percentile": 233.1, "90th_percentile": 233.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 235.53, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 235.53, "10th_percentile": 235.53, "90th_percentile": 235.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH COMPSYCH", "standard_charge_dollar": 270.26, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 270.26, "10th_percentile": 270.26, "90th_percentile": 270.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 55.06, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 55.06, "10th_percentile": 55.06, "90th_percentile": 55.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 212.83, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 212.83, "10th_percentile": 212.83, "90th_percentile": 212.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 121.75, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 121.75, "10th_percentile": 121.75, "90th_percentile": 121.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 73.64, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 73.64, "10th_percentile": 73.64, "90th_percentile": 73.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 165.53, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 165.53, "10th_percentile": 165.53, "90th_percentile": 165.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 270.26, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 270.26, "10th_percentile": 270.26, "90th_percentile": 270.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 337.82, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 337.82, "10th_percentile": 337.82, "90th_percentile": 337.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 178.03, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 178.03, "10th_percentile": 178.03, "90th_percentile": 178.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 160.13, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 160.13, "10th_percentile": 160.13, "90th_percentile": 160.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 287.15, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 287.15, "10th_percentile": 287.15, "90th_percentile": 287.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 168.91, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 168.91, "10th_percentile": 168.91, "90th_percentile": 168.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 253.37, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 253.37, "10th_percentile": 253.37, "90th_percentile": 253.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 219.58, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 219.58, "10th_percentile": 219.58, "90th_percentile": 219.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 209.45, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 209.45, "10th_percentile": 209.45, "90th_percentile": 209.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 209.45, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 209.45, "10th_percentile": 209.45, "90th_percentile": 209.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 337.82, "10th_percentile": 337.82, "90th_percentile": 337.82, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 337.82, "10th_percentile": 337.82, "90th_percentile": 337.82, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 337.82, "10th_percentile": 337.82, "90th_percentile": 337.82, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 337.82, "10th_percentile": 337.82, "90th_percentile": 337.82, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 337.82, "10th_percentile": 337.82, "90th_percentile": 337.82, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 337.82, "10th_percentile": 337.82, "90th_percentile": 337.82, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 337.82, "10th_percentile": 337.82, "90th_percentile": 337.82, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 337.82, "10th_percentile": 337.82, "90th_percentile": 337.82, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 337.82, "10th_percentile": 337.82, "90th_percentile": 337.82, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 337.82, "10th_percentile": 337.82, "90th_percentile": 337.82, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 337.82, "10th_percentile": 337.82, "90th_percentile": 337.82, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "CAPSURE SENSE MRI SURESCAN 4074- 52CM PACEMAKER LEAD", "code_information": [ { "code": "SUP-160173", "type": "CDM" }, { "code": "C1898", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 781.42, "maximum": 5319.38, "setting": "outpatient", "gross_charge": 5319.38, "discounted_cash": 3723.57, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 867.06, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 867.06, "10th_percentile": 867.06, "90th_percentile": 867.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 957.49, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 957.49, "10th_percentile": 957.49, "90th_percentile": 957.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 1239.42, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 1239.42, "10th_percentile": 1239.42, "90th_percentile": 1239.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 792.59, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 792.59, "10th_percentile": 792.59, "90th_percentile": 792.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 792.59, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 792.59, "10th_percentile": 792.59, "90th_percentile": 792.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 3708.67, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3708.67, "10th_percentile": 3708.67, "90th_percentile": 3708.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 4787.44, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 4787.44, "10th_percentile": 4787.44, "90th_percentile": 4787.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 781.42, "standard_charge_percentage": 14.69, "standard_charge_algorithm": "Implant/Prosthetic Rev Code 278; 14.69% Billed", "median_amount": 781.42, "10th_percentile": 781.42, "90th_percentile": 781.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Implant/Prosthetic Rev Code 278; 14.69% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 781.42, "standard_charge_percentage": 14.69, "standard_charge_algorithm": "Implant/Prosthetic Rev Code 278; 14.69% Billed", "median_amount": 781.42, "10th_percentile": 781.42, "90th_percentile": 781.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Implant/Prosthetic Rev Code 278; 14.69% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5319.38, "10th_percentile": 5319.38, "90th_percentile": 5319.38, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5319.38, "10th_percentile": 5319.38, "90th_percentile": 5319.38, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5319.38, "10th_percentile": 5319.38, "90th_percentile": 5319.38, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5319.38, "10th_percentile": 5319.38, "90th_percentile": 5319.38, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 2659.69, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2659.69, "10th_percentile": 2659.69, "90th_percentile": 2659.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 1159.62, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1159.62, "10th_percentile": 1159.62, "90th_percentile": 1159.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 4255.5, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 4255.5, "10th_percentile": 4255.5, "90th_percentile": 4255.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 2606.5, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2606.5, "10th_percentile": 2606.5, "90th_percentile": 2606.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 4255.5, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 4255.5, "10th_percentile": 4255.5, "90th_percentile": 4255.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 3670.37, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 3670.37, "10th_percentile": 3670.37, "90th_percentile": 3670.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 3989.54, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 3989.54, "10th_percentile": 3989.54, "90th_percentile": 3989.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 2659.69, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 2659.69, "10th_percentile": 2659.69, "90th_percentile": 2659.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 3457.6, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 3457.6, "10th_percentile": 3457.6, "90th_percentile": 3457.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 4521.47, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 4521.47, "10th_percentile": 4521.47, "90th_percentile": 4521.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 3351.21, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 3351.21, "10th_percentile": 3351.21, "90th_percentile": 3351.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 3989.54, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 3989.54, "10th_percentile": 3989.54, "90th_percentile": 3989.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 3416.64, "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": 3416.64, "10th_percentile": 3416.64, "90th_percentile": 3416.64, "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": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 2521.39, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2521.39, "10th_percentile": 2521.39, "90th_percentile": 2521.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 2803.31, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2803.31, "10th_percentile": 2803.31, "90th_percentile": 2803.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 5319.38, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 5319.38, "10th_percentile": 5319.38, "90th_percentile": 5319.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2973.53, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2973.53, "10th_percentile": 2973.53, "90th_percentile": 2973.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 1239.42, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 1239.42, "10th_percentile": 1239.42, "90th_percentile": 1239.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5319.38, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5319.38, "10th_percentile": 5319.38, "90th_percentile": 5319.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 3708.67, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3708.67, "10th_percentile": 3708.67, "90th_percentile": 3708.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 4787.44, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 4787.44, "10th_percentile": 4787.44, "90th_percentile": 4787.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 781.42, "standard_charge_percentage": 14.69, "standard_charge_algorithm": "Implant/Prosthetic Rev Code 278; 14.69% Billed", "median_amount": 781.42, "10th_percentile": 781.42, "90th_percentile": 781.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Implant/Prosthetic Rev Code 278; 14.69% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $5,319.38 @ 12.5% = $664.92 due to $0.00 Claim Price", "median_amount": 664.92, "10th_percentile": 664.92, "90th_percentile": 664.92, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $5,319.38 @ 12.5% = $664.92 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $5,319.38 @ 6.8% = $361.72 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": 361.72, "10th_percentile": 361.72, "90th_percentile": 361.72, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $5,319.38 @ 6.8% = $361.72 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $5,319.38 @ 6.8% = $361.72 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": 361.72, "10th_percentile": 361.72, "90th_percentile": 361.72, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $5,319.38 @ 6.8% = $361.72 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": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $5,319.38 @ 6.8% = $361.72 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": 361.72, "10th_percentile": 361.72, "90th_percentile": 361.72, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $5,319.38 @ 6.8% = $361.72 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": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 5319.38, "10th_percentile": 5319.38, "90th_percentile": 5319.38, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5319.38, "10th_percentile": 5319.38, "90th_percentile": 5319.38, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5319.38, "10th_percentile": 5319.38, "90th_percentile": 5319.38, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "CARBIDOPA-LEVODOPA 10-100 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-9406", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "00093-9701-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.73, "maximum": 4.5, "setting": "outpatient", "gross_charge": 4.5, "discounted_cash": 3.15, "payers_information": [ { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 0.98, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.98, "10th_percentile": 0.98, "90th_percentile": 0.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 3.06, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.06, "10th_percentile": 3.06, "90th_percentile": 3.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.73, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 0.73, "10th_percentile": 0.73, "90th_percentile": 0.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 2.21, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.21, "10th_percentile": 2.21, "90th_percentile": 2.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1.26, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.26, "10th_percentile": 1.26, "90th_percentile": 1.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1.27, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.27, "10th_percentile": 1.27, "90th_percentile": 1.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1.3, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2.52, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.52, "10th_percentile": 2.52, "90th_percentile": 2.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 4.05, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% 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 SERVICES; 90% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH 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": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 1.62, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.62, "10th_percentile": 1.62, "90th_percentile": 1.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 1.62, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.62, "10th_percentile": 1.62, "90th_percentile": 1.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 2.79, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.79, "10th_percentile": 2.79, "90th_percentile": 2.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 2.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 3.14, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.14, "10th_percentile": 3.14, "90th_percentile": 3.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 3.14, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.14, "10th_percentile": 3.14, "90th_percentile": 3.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "DCH BLUE CROSS 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": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "DCH 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": "DCH 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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "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": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH 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": "GLOBAL EXCEL [1712]", "plan_name": "DCH 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": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "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": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "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": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "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": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 4.05, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% 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 SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 2.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 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 SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 3.38, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 3.38, "10th_percentile": 3.38, "90th_percentile": 3.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 3.38, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 3.38, "10th_percentile": 3.38, "90th_percentile": 3.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 2.79, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.79, "10th_percentile": 2.79, "90th_percentile": 2.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH COMPSYCH", "standard_charge_dollar": 3.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 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 DEF; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH 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": "MULTIPLAN/PHCS [142]", "plan_name": "DCH 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": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 2.93, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% 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 procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH 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": "DCH 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": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 3.11, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 3.11, "10th_percentile": 3.11, "90th_percentile": 3.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 3.83, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 3.83, "10th_percentile": 3.83, "90th_percentile": 3.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 2.13, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.13, "10th_percentile": 2.13, "90th_percentile": 2.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 2.37, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.37, "10th_percentile": 2.37, "90th_percentile": 2.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "CARBIDOPA-LEVODOPA 87.5-350 MG ORAL CPIE", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-246519", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "64896-0970-16", "type": "NDC" } ], "standard_charges": [ { "minimum": 16.22, "maximum": 99.5, "setting": "outpatient", "gross_charge": 99.5, "discounted_cash": 69.65, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 27.86, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 27.86, "10th_percentile": 27.86, "90th_percentile": 27.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 55.62, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 55.62, "10th_percentile": 55.62, "90th_percentile": 55.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 35.86, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 35.86, "10th_percentile": 35.86, "90th_percentile": 35.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 28.14, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 28.14, "10th_percentile": 28.14, "90th_percentile": 28.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 28.7, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 28.7, "10th_percentile": 28.7, "90th_percentile": 28.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 69.37, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 69.37, "10th_percentile": 69.37, "90th_percentile": 69.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 61.69, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 61.69, "10th_percentile": 61.69, "90th_percentile": 61.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 89.55, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 89.55, "10th_percentile": 89.55, "90th_percentile": 89.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 89.55, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 89.55, "10th_percentile": 89.55, "90th_percentile": 89.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 84.58, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 84.58, "10th_percentile": 84.58, "90th_percentile": 84.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 74.63, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 74.63, "10th_percentile": 74.63, "90th_percentile": 74.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 64.68, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 64.68, "10th_percentile": 64.68, "90th_percentile": 64.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 49.75, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 49.75, "10th_percentile": 49.75, "90th_percentile": 49.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 48.76, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 48.76, "10th_percentile": 48.76, "90th_percentile": 48.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 49.75, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 49.75, "10th_percentile": 49.75, "90th_percentile": 49.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 99.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 99.5, "10th_percentile": 99.5, "90th_percentile": 99.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 79.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 79.6, "10th_percentile": 79.6, "90th_percentile": 79.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 52.44, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 52.44, "10th_percentile": 52.44, "90th_percentile": 52.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 47.16, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 47.16, "10th_percentile": 47.16, "90th_percentile": 47.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 62.69, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 62.69, "10th_percentile": 62.69, "90th_percentile": 62.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 68.66, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 68.66, "10th_percentile": 68.66, "90th_percentile": 68.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 63.91, "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": 63.91, "10th_percentile": 63.91, "90th_percentile": 63.91, "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": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 74.63, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 74.63, "10th_percentile": 74.63, "90th_percentile": 74.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 21.69, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 21.69, "10th_percentile": 21.69, "90th_percentile": 21.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 99.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 99.5, "10th_percentile": 99.5, "90th_percentile": 99.5, "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": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 79.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 79.6, "10th_percentile": 79.6, "90th_percentile": 79.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 99.5, "10th_percentile": 99.5, "90th_percentile": 99.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 99.5, "10th_percentile": 99.5, "90th_percentile": 99.5, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 99.5, "10th_percentile": 99.5, "90th_percentile": 99.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 99.5, "10th_percentile": 99.5, "90th_percentile": 99.5, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 99.5, "10th_percentile": 99.5, "90th_percentile": 99.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 99.5, "10th_percentile": 99.5, "90th_percentile": 99.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 99.5, "10th_percentile": 99.5, "90th_percentile": 99.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 99.5, "10th_percentile": 99.5, "90th_percentile": 99.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 99.5, "10th_percentile": 99.5, "90th_percentile": 99.5, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 99.5, "10th_percentile": 99.5, "90th_percentile": 99.5, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 99.5, "10th_percentile": 99.5, "90th_percentile": 99.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 61.69, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 61.69, "10th_percentile": 61.69, "90th_percentile": 61.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 67.56, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 67.56, "10th_percentile": 67.56, "90th_percentile": 67.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 69.37, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 69.37, "10th_percentile": 69.37, "90th_percentile": 69.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 35.86, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 35.86, "10th_percentile": 35.86, "90th_percentile": 35.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 16.22, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 16.22, "10th_percentile": 16.22, "90th_percentile": 16.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" } ] } ] }, { "description": "CARBOPLATIN 10 MG/ML IV SOLN", "drug_information": { "unit": 45.0, "type": "ML" }, "code_information": [ { "code": "RX-39267", "type": "CDM" }, { "code": "J9045", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "00703-4248-81", "type": "NDC" } ], "standard_charges": [ { "minimum": 213.33, "maximum": 1431.75, "setting": "outpatient", "gross_charge": 1431.75, "discounted_cash": 1002.22, "payers_information": [ { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1431.75, "10th_percentile": 1431.75, "90th_percentile": 1431.75, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1431.75, "10th_percentile": 1431.75, "90th_percentile": 1431.75, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1431.75, "10th_percentile": 1431.75, "90th_percentile": 1431.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1431.75, "10th_percentile": 1431.75, "90th_percentile": 1431.75, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1431.75, "10th_percentile": 1431.75, "90th_percentile": 1431.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1431.75, "10th_percentile": 1431.75, "90th_percentile": 1431.75, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 1431.75, "10th_percentile": 1431.75, "90th_percentile": 1431.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,431.75 @ 12.5% = $178.97 due to $0.00 Claim Price", "median_amount": 178.97, "10th_percentile": 178.97, "90th_percentile": 178.97, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,431.75 @ 12.5% = $178.97 due to $0.00 Claim Price" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,431.75 @ 6.8% = $97.36 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": 97.36, "10th_percentile": 97.36, "90th_percentile": 97.36, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,431.75 @ 6.8% = $97.36 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,431.75 @ 6.8% = $97.36 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": 97.36, "10th_percentile": 97.36, "90th_percentile": 97.36, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,431.75 @ 6.8% = $97.36 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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,431.75 @ 6.8% = $97.36 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": 97.36, "10th_percentile": 97.36, "90th_percentile": 97.36, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,431.75 @ 6.8% = $97.36 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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 333.6, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 333.6, "10th_percentile": 333.6, "90th_percentile": 333.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 257.72, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 257.72, "10th_percentile": 257.72, "90th_percentile": 257.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 800.35, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 800.35, "10th_percentile": 800.35, "90th_percentile": 800.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 998.22, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 998.22, "10th_percentile": 998.22, "90th_percentile": 998.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 213.33, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 213.33, "10th_percentile": 213.33, "90th_percentile": 213.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 213.33, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 213.33, "10th_percentile": 213.33, "90th_percentile": 213.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 1288.58, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 1288.58, "10th_percentile": 1288.58, "90th_percentile": 1288.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 1288.58, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 1288.58, "10th_percentile": 1288.58, "90th_percentile": 1288.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 930.64, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 930.64, "10th_percentile": 930.64, "90th_percentile": 930.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 1073.81, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 1073.81, "10th_percentile": 1073.81, "90th_percentile": 1073.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 715.88, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 715.88, "10th_percentile": 715.88, "90th_percentile": 715.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 1216.99, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 1216.99, "10th_percentile": 1216.99, "90th_percentile": 1216.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 998.22, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 998.22, "10th_percentile": 998.22, "90th_percentile": 998.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 987.91, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 987.91, "10th_percentile": 987.91, "90th_percentile": 987.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1145.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 1145.4, "10th_percentile": 1145.4, "90th_percentile": 1145.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 715.88, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 715.88, "10th_percentile": 715.88, "90th_percentile": 715.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 1073.81, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 1073.81, "10th_percentile": 1073.81, "90th_percentile": 1073.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 902.0, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 902.0, "10th_percentile": 902.0, "90th_percentile": 902.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 1145.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 1145.4, "10th_percentile": 1145.4, "90th_percentile": 1145.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 233.38, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 233.38, "10th_percentile": 233.38, "90th_percentile": 233.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1431.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1431.75, "10th_percentile": 1431.75, "90th_percentile": 1431.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 333.6, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 333.6, "10th_percentile": 333.6, "90th_percentile": 333.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1431.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1431.75, "10th_percentile": 1431.75, "90th_percentile": 1431.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "CARBOPLATIN 10 MG/ML IV SOLN", "drug_information": { "unit": 60.0, "type": "ML" }, "code_information": [ { "code": "RX-39267", "type": "CDM" }, { "code": "J9045", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "61703-0339-56", "type": "NDC" } ], "standard_charges": [ { "minimum": 193.81, "maximum": 1300.75, "setting": "outpatient", "gross_charge": 1300.75, "discounted_cash": 910.52, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1300.75, "10th_percentile": 1300.75, "90th_percentile": 1300.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1300.75, "10th_percentile": 1300.75, "90th_percentile": 1300.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1300.75, "10th_percentile": 1300.75, "90th_percentile": 1300.75, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1300.75, "10th_percentile": 1300.75, "90th_percentile": 1300.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1300.75, "10th_percentile": 1300.75, "90th_percentile": 1300.75, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1300.75, "10th_percentile": 1300.75, "90th_percentile": 1300.75, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 1300.75, "10th_percentile": 1300.75, "90th_percentile": 1300.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,300.75 @ 12.5% = $162.59 due to $0.00 Claim Price", "median_amount": 162.59, "10th_percentile": 162.59, "90th_percentile": 162.59, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,300.75 @ 12.5% = $162.59 due to $0.00 Claim Price" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,300.75 @ 6.8% = $88.45 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": 88.45, "10th_percentile": 88.45, "90th_percentile": 88.45, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,300.75 @ 6.8% = $88.45 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,300.75 @ 6.8% = $88.45 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": 88.45, "10th_percentile": 88.45, "90th_percentile": 88.45, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,300.75 @ 6.8% = $88.45 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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,300.75 @ 6.8% = $88.45 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": 88.45, "10th_percentile": 88.45, "90th_percentile": 88.45, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,300.75 @ 6.8% = $88.45 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 BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 906.88, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 906.88, "10th_percentile": 906.88, "90th_percentile": 906.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 906.88, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 906.88, "10th_percentile": 906.88, "90th_percentile": 906.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 303.07, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 303.07, "10th_percentile": 303.07, "90th_percentile": 303.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 303.07, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 303.07, "10th_percentile": 303.07, "90th_percentile": 303.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 1170.68, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 1170.68, "10th_percentile": 1170.68, "90th_percentile": 1170.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 1170.68, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 1170.68, "10th_percentile": 1170.68, "90th_percentile": 1170.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 193.81, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 193.81, "10th_percentile": 193.81, "90th_percentile": 193.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 193.81, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 193.81, "10th_percentile": 193.81, "90th_percentile": 193.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH HFN PPO", "standard_charge_dollar": 1105.64, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 1105.64, "10th_percentile": 1105.64, "90th_percentile": 1105.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 650.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 650.38, "10th_percentile": 650.38, "90th_percentile": 650.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 975.56, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 975.56, "10th_percentile": 975.56, "90th_percentile": 975.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 845.49, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 845.49, "10th_percentile": 845.49, "90th_percentile": 845.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 650.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 650.38, "10th_percentile": 650.38, "90th_percentile": 650.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 727.12, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 727.12, "10th_percentile": 727.12, "90th_percentile": 727.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 819.47, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 819.47, "10th_percentile": 819.47, "90th_percentile": 819.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 975.56, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 975.56, "10th_percentile": 975.56, "90th_percentile": 975.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1040.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 1040.6, "10th_percentile": 1040.6, "90th_percentile": 1040.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 897.52, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 897.52, "10th_percentile": 897.52, "90th_percentile": 897.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1300.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1300.75, "10th_percentile": 1300.75, "90th_percentile": 1300.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 1040.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 1040.6, "10th_percentile": 1040.6, "90th_percentile": 1040.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1300.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1300.75, "10th_percentile": 1300.75, "90th_percentile": 1300.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 234.14, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 234.14, "10th_percentile": 234.14, "90th_percentile": 234.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 212.02, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 212.02, "10th_percentile": 212.02, "90th_percentile": 212.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" } ] } ] }, { "description": "CARBOXYMETHYLCELLULOSE SODIUM 1 % OPHT DPGE", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-101586", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "00023-4554-30", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.69, "maximum": 4.25, "setting": "outpatient", "gross_charge": 4.25, "discounted_cash": 2.97, "payers_information": [ { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4.25, "10th_percentile": 4.25, "90th_percentile": 4.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4.25, "10th_percentile": 4.25, "90th_percentile": 4.25, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4.25, "10th_percentile": 4.25, "90th_percentile": 4.25, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4.25, "10th_percentile": 4.25, "90th_percentile": 4.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4.25, "10th_percentile": 4.25, "90th_percentile": 4.25, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4.25, "10th_percentile": 4.25, "90th_percentile": 4.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4.25, "10th_percentile": 4.25, "90th_percentile": 4.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4.25, "10th_percentile": 4.25, "90th_percentile": 4.25, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4.25, "10th_percentile": 4.25, "90th_percentile": 4.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4.25, "10th_percentile": 4.25, "90th_percentile": 4.25, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 4.25, "10th_percentile": 4.25, "90th_percentile": 4.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1.2, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.2, "10th_percentile": 1.2, "90th_percentile": 1.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1.23, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.23, "10th_percentile": 1.23, "90th_percentile": 1.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 1.53, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.53, "10th_percentile": 1.53, "90th_percentile": 1.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2.38, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.38, "10th_percentile": 2.38, "90th_percentile": 2.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 2.96, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.96, "10th_percentile": 2.96, "90th_percentile": 2.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1.19, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 2.64, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.64, "10th_percentile": 2.64, "90th_percentile": 2.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 2.64, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.64, "10th_percentile": 2.64, "90th_percentile": 2.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 3.83, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 3.83, "10th_percentile": 3.83, "90th_percentile": 3.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 3.83, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 3.83, "10th_percentile": 3.83, "90th_percentile": 3.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 3.19, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 3.19, "10th_percentile": 3.19, "90th_percentile": 3.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 2.76, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 2.76, "10th_percentile": 2.76, "90th_percentile": 2.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 2.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 2.13, "10th_percentile": 2.13, "90th_percentile": 2.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 3.61, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 3.61, "10th_percentile": 3.61, "90th_percentile": 3.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 2.01, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.01, "10th_percentile": 2.01, "90th_percentile": 2.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 2.24, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.24, "10th_percentile": 2.24, "90th_percentile": 2.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 4.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 4.25, "10th_percentile": 4.25, "90th_percentile": 4.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4.25, "10th_percentile": 4.25, "90th_percentile": 4.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 2.89, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.89, "10th_percentile": 2.89, "90th_percentile": 2.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.69, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 0.69, "10th_percentile": 0.69, "90th_percentile": 0.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 0.93, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.93, "10th_percentile": 0.93, "90th_percentile": 0.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 2.08, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.08, "10th_percentile": 2.08, "90th_percentile": 2.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 3.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 3.4, "10th_percentile": 3.4, "90th_percentile": 3.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 2.73, "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": 2.73, "10th_percentile": 2.73, "90th_percentile": 2.73, "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": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 2.68, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 2.68, "10th_percentile": 2.68, "90th_percentile": 2.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 3.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 3.4, "10th_percentile": 3.4, "90th_percentile": 3.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 2.93, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% 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 Outpatient Services; 69% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 3.19, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 3.19, "10th_percentile": 3.19, "90th_percentile": 3.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 2.96, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.96, "10th_percentile": 2.96, "90th_percentile": 2.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 2.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.13, "10th_percentile": 2.13, "90th_percentile": 2.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 1.53, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.53, "10th_percentile": 1.53, "90th_percentile": 1.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "CARFILZOMIB 60 MG IV SOLR", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-195636", "type": "CDM" }, { "code": "J9047", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "76075-0101-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 2074.6, "maximum": 13923.5, "setting": "outpatient", "gross_charge": 13923.5, "discounted_cash": 9746.45, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 13923.5, "10th_percentile": 13923.5, "90th_percentile": 13923.5, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 13923.5, "10th_percentile": 13923.5, "90th_percentile": 13923.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 13923.5, "10th_percentile": 13923.5, "90th_percentile": 13923.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 13923.5, "10th_percentile": 13923.5, "90th_percentile": 13923.5, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 13923.5, "10th_percentile": 13923.5, "90th_percentile": 13923.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 13923.5, "10th_percentile": 13923.5, "90th_percentile": 13923.5, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 13923.5, "10th_percentile": 13923.5, "90th_percentile": 13923.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $13,923.50 @ 6.8% = $946.80 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": 946.8, "10th_percentile": 946.8, "90th_percentile": 946.8, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $13,923.50 @ 6.8% = $946.80 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": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $13,923.50 @ 6.8% = $946.80 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": 946.8, "10th_percentile": 946.8, "90th_percentile": 946.8, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $13,923.50 @ 6.8% = $946.80 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $13,923.50 @ 6.8% = $946.80 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": 946.8, "10th_percentile": 946.8, "90th_percentile": 946.8, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $13,923.50 @ 6.8% = $946.80 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": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $13,923.50 @ 12.5% = $1,740.44 due to $0.00 Claim Price", "median_amount": 1740.44, "10th_percentile": 1740.44, "90th_percentile": 1740.44, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $13,923.50 @ 12.5% = $1,740.44 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 2506.23, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2506.23, "10th_percentile": 2506.23, "90th_percentile": 2506.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 2269.53, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 2269.53, "10th_percentile": 2269.53, "90th_percentile": 2269.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 7783.24, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7783.24, "10th_percentile": 7783.24, "90th_percentile": 7783.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 6961.75, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6961.75, "10th_percentile": 6961.75, "90th_percentile": 6961.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 10442.63, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 10442.63, "10th_percentile": 10442.63, "90th_percentile": 10442.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 13923.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 13923.5, "10th_percentile": 13923.5, "90th_percentile": 13923.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 9607.22, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 9607.22, "10th_percentile": 9607.22, "90th_percentile": 9607.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 11138.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 11138.8, "10th_percentile": 11138.8, "90th_percentile": 11138.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 11138.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 11138.8, "10th_percentile": 11138.8, "90th_percentile": 11138.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 13923.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 13923.5, "10th_percentile": 13923.5, "90th_percentile": 13923.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 8771.81, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 8771.81, "10th_percentile": 8771.81, "90th_percentile": 8771.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 11834.98, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 11834.98, "10th_percentile": 11834.98, "90th_percentile": 11834.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 6961.75, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 6961.75, "10th_percentile": 6961.75, "90th_percentile": 6961.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 10442.63, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 10442.63, "10th_percentile": 10442.63, "90th_percentile": 10442.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 9050.28, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 9050.28, "10th_percentile": 9050.28, "90th_percentile": 9050.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 2074.6, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2074.6, "10th_percentile": 2074.6, "90th_percentile": 2074.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 2074.6, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2074.6, "10th_percentile": 2074.6, "90th_percentile": 2074.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 12531.15, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 12531.15, "10th_percentile": 12531.15, "90th_percentile": 12531.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 12531.15, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 12531.15, "10th_percentile": 12531.15, "90th_percentile": 12531.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 3244.18, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 3244.18, "10th_percentile": 3244.18, "90th_percentile": 3244.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 3244.18, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 3244.18, "10th_percentile": 3244.18, "90th_percentile": 3244.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 9707.46, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9707.46, "10th_percentile": 9707.46, "90th_percentile": 9707.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 9707.46, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9707.46, "10th_percentile": 9707.46, "90th_percentile": 9707.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "CAROITID WALLSTENT 8MM X 36MM X 135CM ENDOPROS SLFE XP TRCHBR R", "code_information": [ { "code": "SUP-312036", "type": "CDM" }, { "code": "C1876", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 3028.89, "maximum": 20618.75, "setting": "outpatient", "gross_charge": 20618.75, "discounted_cash": 14433.12, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 3360.86, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 3360.86, "10th_percentile": 3360.86, "90th_percentile": 3360.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 20618.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 20618.75, "10th_percentile": 20618.75, "90th_percentile": 20618.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 10309.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10309.38, "10th_percentile": 10309.38, "90th_percentile": 10309.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 4494.89, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4494.89, "10th_percentile": 4494.89, "90th_percentile": 4494.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 16495.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 16495.0, "10th_percentile": 16495.0, "90th_percentile": 16495.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 10103.19, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10103.19, "10th_percentile": 10103.19, "90th_percentile": 10103.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 16495.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 16495.0, "10th_percentile": 16495.0, "90th_percentile": 16495.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 14226.94, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 14226.94, "10th_percentile": 14226.94, "90th_percentile": 14226.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 15464.06, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 15464.06, "10th_percentile": 15464.06, "90th_percentile": 15464.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 10309.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 10309.38, "10th_percentile": 10309.38, "90th_percentile": 10309.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 13402.19, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 13402.19, "10th_percentile": 13402.19, "90th_percentile": 13402.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 17525.94, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 17525.94, "10th_percentile": 17525.94, "90th_percentile": 17525.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 12989.81, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 12989.81, "10th_percentile": 12989.81, "90th_percentile": 12989.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 15464.06, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 15464.06, "10th_percentile": 15464.06, "90th_percentile": 15464.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 13243.42, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 13243.42, "10th_percentile": 13243.42, "90th_percentile": 13243.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 9773.29, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9773.29, "10th_percentile": 9773.29, "90th_percentile": 9773.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 10866.08, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10866.08, "10th_percentile": 10866.08, "90th_percentile": 10866.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 20618.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 20618.75, "10th_percentile": 20618.75, "90th_percentile": 20618.75, "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": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 11525.88, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11525.88, "10th_percentile": 11525.88, "90th_percentile": 11525.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 3711.38, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3711.38, "10th_percentile": 3711.38, "90th_percentile": 3711.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 3072.19, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3072.19, "10th_percentile": 3072.19, "90th_percentile": 3072.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 3072.19, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3072.19, "10th_percentile": 3072.19, "90th_percentile": 3072.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 14375.39, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14375.39, "10th_percentile": 14375.39, "90th_percentile": 14375.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 14375.39, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14375.39, "10th_percentile": 14375.39, "90th_percentile": 14375.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 18556.88, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 18556.88, "10th_percentile": 18556.88, "90th_percentile": 18556.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 18556.88, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 18556.88, "10th_percentile": 18556.88, "90th_percentile": 18556.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 4804.17, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 4804.17, "10th_percentile": 4804.17, "90th_percentile": 4804.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 4804.17, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 4804.17, "10th_percentile": 4804.17, "90th_percentile": 4804.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 3028.89, "standard_charge_percentage": 14.69, "standard_charge_algorithm": "Implant/Prosthetic Rev Code 278; 14.69% Billed", "median_amount": 3028.89, "10th_percentile": 3028.89, "90th_percentile": 3028.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Implant/Prosthetic Rev Code 278; 14.69% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 3028.89, "standard_charge_percentage": 14.69, "standard_charge_algorithm": "Implant/Prosthetic Rev Code 278; 14.69% Billed", "median_amount": 3028.89, "10th_percentile": 3028.89, "90th_percentile": 3028.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Implant/Prosthetic Rev Code 278; 14.69% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 3028.89, "standard_charge_percentage": 14.69, "standard_charge_algorithm": "Implant/Prosthetic Rev Code 278; 14.69% Billed", "median_amount": 3028.89, "10th_percentile": 3028.89, "90th_percentile": 3028.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Implant/Prosthetic Rev Code 278; 14.69% Billed" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $20,618.75 @ 6.8% = $1,402.08 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": 1402.08, "10th_percentile": 1402.08, "90th_percentile": 1402.08, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $20,618.75 @ 6.8% = $1,402.08 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": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $20,618.75 @ 6.8% = $1,402.08 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": 1402.08, "10th_percentile": 1402.08, "90th_percentile": 1402.08, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $20,618.75 @ 6.8% = $1,402.08 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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $20,618.75 @ 6.8% = $1,402.08 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": 1402.08, "10th_percentile": 1402.08, "90th_percentile": 1402.08, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $20,618.75 @ 6.8% = $1,402.08 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": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $20,618.75 @ 12.5% = $2,577.34 due to $0.00 Claim Price", "median_amount": 2577.34, "10th_percentile": 2577.34, "90th_percentile": 2577.34, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $20,618.75 @ 12.5% = $2,577.34 due to $0.00 Claim Price" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 20618.75, "10th_percentile": 20618.75, "90th_percentile": 20618.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 20618.75, "10th_percentile": 20618.75, "90th_percentile": 20618.75, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 20618.75, "10th_percentile": 20618.75, "90th_percentile": 20618.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 20618.75, "10th_percentile": 20618.75, "90th_percentile": 20618.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 20618.75, "10th_percentile": 20618.75, "90th_percentile": 20618.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 20618.75, "10th_percentile": 20618.75, "90th_percentile": 20618.75, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 20618.75, "10th_percentile": 20618.75, "90th_percentile": 20618.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "CAROTID STENT 6MM X 22MM X 135CM ENDOPROS SLFEXP TRCHBR R", "code_information": [ { "code": "SUP-312033", "type": "CDM" }, { "code": "C1876", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 3028.89, "maximum": 20618.75, "setting": "outpatient", "gross_charge": 20618.75, "discounted_cash": 14433.12, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 20618.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 20618.75, "10th_percentile": 20618.75, "90th_percentile": 20618.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 3360.86, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 3360.86, "10th_percentile": 3360.86, "90th_percentile": 3360.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 10309.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10309.38, "10th_percentile": 10309.38, "90th_percentile": 10309.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 4494.89, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4494.89, "10th_percentile": 4494.89, "90th_percentile": 4494.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 16495.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 16495.0, "10th_percentile": 16495.0, "90th_percentile": 16495.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 10103.19, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10103.19, "10th_percentile": 10103.19, "90th_percentile": 10103.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 16495.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 16495.0, "10th_percentile": 16495.0, "90th_percentile": 16495.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 14226.94, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 14226.94, "10th_percentile": 14226.94, "90th_percentile": 14226.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 15464.06, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 15464.06, "10th_percentile": 15464.06, "90th_percentile": 15464.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 10309.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 10309.38, "10th_percentile": 10309.38, "90th_percentile": 10309.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 13402.19, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 13402.19, "10th_percentile": 13402.19, "90th_percentile": 13402.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 17525.94, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 17525.94, "10th_percentile": 17525.94, "90th_percentile": 17525.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 12989.81, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 12989.81, "10th_percentile": 12989.81, "90th_percentile": 12989.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 15464.06, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 15464.06, "10th_percentile": 15464.06, "90th_percentile": 15464.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 13243.42, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 13243.42, "10th_percentile": 13243.42, "90th_percentile": 13243.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 9773.29, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9773.29, "10th_percentile": 9773.29, "90th_percentile": 9773.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 10866.08, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10866.08, "10th_percentile": 10866.08, "90th_percentile": 10866.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 20618.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 20618.75, "10th_percentile": 20618.75, "90th_percentile": 20618.75, "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": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 3711.38, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3711.38, "10th_percentile": 3711.38, "90th_percentile": 3711.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 11525.88, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11525.88, "10th_percentile": 11525.88, "90th_percentile": 11525.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 3072.19, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3072.19, "10th_percentile": 3072.19, "90th_percentile": 3072.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 3072.19, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3072.19, "10th_percentile": 3072.19, "90th_percentile": 3072.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 14375.39, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14375.39, "10th_percentile": 14375.39, "90th_percentile": 14375.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 14375.39, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14375.39, "10th_percentile": 14375.39, "90th_percentile": 14375.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 18556.88, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 18556.88, "10th_percentile": 18556.88, "90th_percentile": 18556.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 18556.88, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 18556.88, "10th_percentile": 18556.88, "90th_percentile": 18556.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 4804.17, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 4804.17, "10th_percentile": 4804.17, "90th_percentile": 4804.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 4804.17, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 4804.17, "10th_percentile": 4804.17, "90th_percentile": 4804.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 3028.89, "standard_charge_percentage": 14.69, "standard_charge_algorithm": "Implant/Prosthetic Rev Code 278; 14.69% Billed", "median_amount": 3028.89, "10th_percentile": 3028.89, "90th_percentile": 3028.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Implant/Prosthetic Rev Code 278; 14.69% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 3028.89, "standard_charge_percentage": 14.69, "standard_charge_algorithm": "Implant/Prosthetic Rev Code 278; 14.69% Billed", "median_amount": 3028.89, "10th_percentile": 3028.89, "90th_percentile": 3028.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Implant/Prosthetic Rev Code 278; 14.69% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 3028.89, "standard_charge_percentage": 14.69, "standard_charge_algorithm": "Implant/Prosthetic Rev Code 278; 14.69% Billed", "median_amount": 3028.89, "10th_percentile": 3028.89, "90th_percentile": 3028.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Implant/Prosthetic Rev Code 278; 14.69% Billed" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $20,618.75 @ 6.8% = $1,402.08 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": 1402.08, "10th_percentile": 1402.08, "90th_percentile": 1402.08, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $20,618.75 @ 6.8% = $1,402.08 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": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $20,618.75 @ 6.8% = $1,402.08 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": 1402.08, "10th_percentile": 1402.08, "90th_percentile": 1402.08, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $20,618.75 @ 6.8% = $1,402.08 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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $20,618.75 @ 6.8% = $1,402.08 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": 1402.08, "10th_percentile": 1402.08, "90th_percentile": 1402.08, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $20,618.75 @ 6.8% = $1,402.08 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": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $20,618.75 @ 12.5% = $2,577.34 due to $0.00 Claim Price", "median_amount": 2577.34, "10th_percentile": 2577.34, "90th_percentile": 2577.34, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $20,618.75 @ 12.5% = $2,577.34 due to $0.00 Claim Price" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 20618.75, "10th_percentile": 20618.75, "90th_percentile": 20618.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 20618.75, "10th_percentile": 20618.75, "90th_percentile": 20618.75, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 20618.75, "10th_percentile": 20618.75, "90th_percentile": 20618.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 20618.75, "10th_percentile": 20618.75, "90th_percentile": 20618.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 20618.75, "10th_percentile": 20618.75, "90th_percentile": 20618.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 20618.75, "10th_percentile": 20618.75, "90th_percentile": 20618.75, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 20618.75, "10th_percentile": 20618.75, "90th_percentile": 20618.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "CARVEDILOL 3.125 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-18551", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "51079-0771-20", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.73, "maximum": 4.5, "setting": "outpatient", "gross_charge": 4.5, "discounted_cash": 3.15, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 3.06, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.06, "10th_percentile": 3.06, "90th_percentile": 3.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.73, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 0.73, "10th_percentile": 0.73, "90th_percentile": 0.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1.27, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.27, "10th_percentile": 1.27, "90th_percentile": 1.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1.3, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 4.05, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% 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 SERVICES; 90% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 1.62, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.62, "10th_percentile": 1.62, "90th_percentile": 1.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 2.79, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.79, "10th_percentile": 2.79, "90th_percentile": 2.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 3.14, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.14, "10th_percentile": 3.14, "90th_percentile": 3.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "DCH BLUE CROSS 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": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "DCH 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": "DCH 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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "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": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "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": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "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": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH 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": "GLOBAL EXCEL [1712]", "plan_name": "DCH 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": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "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": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 3.11, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 3.11, "10th_percentile": 3.11, "90th_percentile": 3.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 2.21, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.21, "10th_percentile": 2.21, "90th_percentile": 2.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 0.98, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.98, "10th_percentile": 0.98, "90th_percentile": 0.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH 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": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 3.83, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 3.83, "10th_percentile": 3.83, "90th_percentile": 3.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 2.13, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.13, "10th_percentile": 2.13, "90th_percentile": 2.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2.52, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.52, "10th_percentile": 2.52, "90th_percentile": 2.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1.26, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.26, "10th_percentile": 1.26, "90th_percentile": 1.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 2.37, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.37, "10th_percentile": 2.37, "90th_percentile": 2.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH 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": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 2.93, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% 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 procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 3.38, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 3.38, "10th_percentile": 3.38, "90th_percentile": 3.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 3.38, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 3.38, "10th_percentile": 3.38, "90th_percentile": 3.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 2.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 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 SRVS; 50% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 2.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 4.05, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% 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 SERVICES; 90% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 3.14, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.14, "10th_percentile": 3.14, "90th_percentile": 3.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH 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": "DCH 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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 1.62, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.62, "10th_percentile": 1.62, "90th_percentile": 1.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 2.79, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.79, "10th_percentile": 2.79, "90th_percentile": 2.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH COMPSYCH", "standard_charge_dollar": 3.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 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 DEF; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH 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" } ] } ] }, { "description": "CARVEDILOL 12.5 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-15749", "type": "CDM" }, { "code": "J3490", "type": "HCPCS" }, { "code": "0637", "type": "RC" }, { "code": "68001-0151-00", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.67, "maximum": 4.5, "setting": "outpatient", "gross_charge": 4.5, "discounted_cash": 3.15, "payers_information": [ { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "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": "DCH BLUE CROSS 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": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH 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": "DCH 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": "DCH 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": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "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": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $4.50 @ 12.5% = $0.56 due to $0.00 Claim Price", "median_amount": 0.56, "10th_percentile": 0.56, "90th_percentile": 0.56, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $4.50 @ 12.5% = $0.56 due to $0.00 Claim Price" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $4.50 @ 6.8% = $0.31 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": 0.31, "10th_percentile": 0.31, "90th_percentile": 0.31, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $4.50 @ 6.8% = $0.31 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $4.50 @ 6.8% = $0.31 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": 0.31, "10th_percentile": 0.31, "90th_percentile": 0.31, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $4.50 @ 6.8% = $0.31 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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $4.50 @ 6.8% = $0.31 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": 0.31, "10th_percentile": 0.31, "90th_percentile": 0.31, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $4.50 @ 6.8% = $0.31 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": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 2.79, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "Drugs/Agents Default; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.79, "10th_percentile": 2.79, "90th_percentile": 2.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 3.06, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "Drugs/Agents Default; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.06, "10th_percentile": 3.06, "90th_percentile": 3.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.73, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 0.73, "10th_percentile": 0.73, "90th_percentile": 0.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 3.14, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.14, "10th_percentile": 3.14, "90th_percentile": 3.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 1.05, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 4.05, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% 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 SERVICES; 90% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.67, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.67, "10th_percentile": 0.67, "90th_percentile": 0.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.81, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.81, "10th_percentile": 0.81, "90th_percentile": 0.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.67, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.67, "10th_percentile": 0.67, "90th_percentile": 0.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 3.14, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.14, "10th_percentile": 3.14, "90th_percentile": 3.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2.52, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.52, "10th_percentile": 2.52, "90th_percentile": 2.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 1.05, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 2.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH 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": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 3.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 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 DEF; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 2.79, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "Drugs/Agents Default; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.79, "10th_percentile": 2.79, "90th_percentile": 2.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 3.11, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 3.11, "10th_percentile": 3.11, "90th_percentile": 3.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 3.38, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 3.38, "10th_percentile": 3.38, "90th_percentile": 3.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 2.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 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 SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 2.93, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% 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 procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 3.83, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 3.83, "10th_percentile": 3.83, "90th_percentile": 3.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH 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": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 4.05, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% 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 SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 3.38, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 3.38, "10th_percentile": 3.38, "90th_percentile": 3.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH 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": "DCH UHC CORE", "standard_charge_dollar": 2.13, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.13, "10th_percentile": 2.13, "90th_percentile": 2.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 2.37, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.37, "10th_percentile": 2.37, "90th_percentile": 2.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH 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": "MULTIPLAN/PHCS [142]", "plan_name": "DCH 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" } ] } ] }, { "description": "CASPAR DISTRACTION PIN 12MM (2 in pack) 0022-LDR", "code_information": [ { "code": "SUP-337963", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 863.89, "maximum": 5299.92, "setting": "outpatient", "gross_charge": 5299.92, "discounted_cash": 3709.94, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 3285.95, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3285.95, "10th_percentile": 3285.95, "90th_percentile": 3285.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 3285.95, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3285.95, "10th_percentile": 3285.95, "90th_percentile": 3285.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1528.5, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1528.5, "10th_percentile": 1528.5, "90th_percentile": 1528.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 3695.1, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3695.1, "10th_percentile": 3695.1, "90th_percentile": 3695.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1498.82, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1498.82, "10th_percentile": 1498.82, "90th_percentile": 1498.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2962.66, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2962.66, "10th_percentile": 2962.66, "90th_percentile": 2962.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 1910.09, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1910.09, "10th_percentile": 1910.09, "90th_percentile": 1910.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1483.98, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1483.98, "10th_percentile": 1483.98, "90th_percentile": 1483.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 4769.93, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 4769.93, "10th_percentile": 4769.93, "90th_percentile": 4769.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 4769.93, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 4769.93, "10th_percentile": 4769.93, "90th_percentile": 4769.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 2649.96, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 2649.96, "10th_percentile": 2649.96, "90th_percentile": 2649.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 3444.95, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 3444.95, "10th_percentile": 3444.95, "90th_percentile": 3444.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 3974.94, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 3974.94, "10th_percentile": 3974.94, "90th_percentile": 3974.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 4504.93, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 4504.93, "10th_percentile": 4504.93, "90th_percentile": 4504.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 3598.65, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3598.65, "10th_percentile": 3598.65, "90th_percentile": 3598.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5299.92, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5299.92, "10th_percentile": 5299.92, "90th_percentile": 5299.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 4239.94, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 4239.94, "10th_percentile": 4239.94, "90th_percentile": 4239.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 2512.16, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2512.16, "10th_percentile": 2512.16, "90th_percentile": 2512.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 2793.06, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2793.06, "10th_percentile": 2793.06, "90th_percentile": 2793.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 5299.92, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 5299.92, "10th_percentile": 5299.92, "90th_percentile": 5299.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 3404.14, "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": 3404.14, "10th_percentile": 3404.14, "90th_percentile": 3404.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 3974.94, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 3974.94, "10th_percentile": 3974.94, "90th_percentile": 3974.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 1155.38, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1155.38, "10th_percentile": 1155.38, "90th_percentile": 1155.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 4239.94, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 4239.94, "10th_percentile": 4239.94, "90th_percentile": 4239.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 2596.96, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2596.96, "10th_percentile": 2596.96, "90th_percentile": 2596.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 2649.96, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2649.96, "10th_percentile": 2649.96, "90th_percentile": 2649.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 3695.1, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3695.1, "10th_percentile": 3695.1, "90th_percentile": 3695.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 3656.94, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 3656.94, "10th_percentile": 3656.94, "90th_percentile": 3656.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 863.89, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 863.89, "10th_percentile": 863.89, "90th_percentile": 863.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 1910.09, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1910.09, "10th_percentile": 1910.09, "90th_percentile": 1910.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 3338.95, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 3338.95, "10th_percentile": 3338.95, "90th_percentile": 3338.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 5299.92, "10th_percentile": 5299.92, "90th_percentile": 5299.92, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5299.92, "10th_percentile": 5299.92, "90th_percentile": 5299.92, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5299.92, "10th_percentile": 5299.92, "90th_percentile": 5299.92, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5299.92, "10th_percentile": 5299.92, "90th_percentile": 5299.92, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5299.92, "10th_percentile": 5299.92, "90th_percentile": 5299.92, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5299.92, "10th_percentile": 5299.92, "90th_percentile": 5299.92, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5299.92, "10th_percentile": 5299.92, "90th_percentile": 5299.92, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5299.92, "10th_percentile": 5299.92, "90th_percentile": 5299.92, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5299.92, "10th_percentile": 5299.92, "90th_percentile": 5299.92, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5299.92, "10th_percentile": 5299.92, "90th_percentile": 5299.92, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5299.92, "10th_percentile": 5299.92, "90th_percentile": 5299.92, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "CAST FIBERGLASS 5 INCH ROLL 82005", "code_information": [ { "code": "SUP-23277", "type": "CDM" }, { "code": "27103350", "type": "LOCAL" }, { "code": "0271", "type": "RC" } ], "standard_charges": [ { "minimum": 5.85, "maximum": 35.91, "setting": "outpatient", "gross_charge": 35.91, "discounted_cash": 25.14, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 24.38, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 24.38, "10th_percentile": 24.38, "90th_percentile": 24.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 5.85, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 5.85, "10th_percentile": 5.85, "90th_percentile": 5.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 23.06, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 23.06, "10th_percentile": 23.06, "90th_percentile": 23.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 26.93, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 26.93, "10th_percentile": 26.93, "90th_percentile": 26.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 17.96, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 17.96, "10th_percentile": 17.96, "90th_percentile": 17.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 17.02, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 17.02, "10th_percentile": 17.02, "90th_percentile": 17.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 18.92, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 18.92, "10th_percentile": 18.92, "90th_percentile": 18.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 35.91, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 35.91, "10th_percentile": 35.91, "90th_percentile": 35.91, "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": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 7.83, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.83, "10th_percentile": 7.83, "90th_percentile": 7.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH COMPSYCH", "standard_charge_dollar": 28.73, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 28.73, "10th_percentile": 28.73, "90th_percentile": 28.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 22.62, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 22.62, "10th_percentile": 22.62, "90th_percentile": 22.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 35.91, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 35.91, "10th_percentile": 35.91, "90th_percentile": 35.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 24.78, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 24.78, "10th_percentile": 24.78, "90th_percentile": 24.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 10.16, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.16, "10th_percentile": 10.16, "90th_percentile": 10.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 10.36, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.36, "10th_percentile": 10.36, "90th_percentile": 10.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 20.07, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.07, "10th_percentile": 20.07, "90th_percentile": 20.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 10.05, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.05, "10th_percentile": 10.05, "90th_percentile": 10.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 17.6, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 17.6, "10th_percentile": 17.6, "90th_percentile": 17.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 28.73, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 28.73, "10th_percentile": 28.73, "90th_percentile": 28.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 30.52, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 30.52, "10th_percentile": 30.52, "90th_percentile": 30.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 23.34, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 23.34, "10th_percentile": 23.34, "90th_percentile": 23.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 17.96, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 17.96, "10th_percentile": 17.96, "90th_percentile": 17.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 26.93, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 26.93, "10th_percentile": 26.93, "90th_percentile": 26.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 32.32, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 32.32, "10th_percentile": 32.32, "90th_percentile": 32.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 32.32, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 32.32, "10th_percentile": 32.32, "90th_percentile": 32.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 22.26, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 22.26, "10th_percentile": 22.26, "90th_percentile": 22.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 22.26, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 22.26, "10th_percentile": 22.26, "90th_percentile": 22.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 12.94, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 12.94, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 25.04, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 25.04, "10th_percentile": 25.04, "90th_percentile": 25.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 25.04, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 25.04, "10th_percentile": 25.04, "90th_percentile": 25.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 35.91, "10th_percentile": 35.91, "90th_percentile": 35.91, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 35.91, "10th_percentile": 35.91, "90th_percentile": 35.91, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 35.91, "10th_percentile": 35.91, "90th_percentile": 35.91, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 35.91, "10th_percentile": 35.91, "90th_percentile": 35.91, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 35.91, "10th_percentile": 35.91, "90th_percentile": 35.91, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 35.91, "10th_percentile": 35.91, "90th_percentile": 35.91, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 35.91, "10th_percentile": 35.91, "90th_percentile": 35.91, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 35.91, "10th_percentile": 35.91, "90th_percentile": 35.91, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 35.91, "10th_percentile": 35.91, "90th_percentile": 35.91, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 35.91, "10th_percentile": 35.91, "90th_percentile": 35.91, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 35.91, "10th_percentile": 35.91, "90th_percentile": 35.91, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "CATH ABLAT LG CRV 4MM TIP QPLR", "code_information": [ { "code": "SUP-301880", "type": "CDM" }, { "code": "C1733", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 1192.55, "maximum": 8003.66, "setting": "outpatient", "gross_charge": 8003.66, "discounted_cash": 5602.56, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 4962.27, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4962.27, "10th_percentile": 4962.27, "90th_percentile": 4962.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 5434.49, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5434.49, "10th_percentile": 5434.49, "90th_percentile": 5434.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 1304.6, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 1304.6, "10th_percentile": 1304.6, "90th_percentile": 1304.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 5580.15, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5580.15, "10th_percentile": 5580.15, "90th_percentile": 5580.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 1864.85, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 1864.85, "10th_percentile": 1864.85, "90th_percentile": 1864.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 7203.29, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 7203.29, "10th_percentile": 7203.29, "90th_percentile": 7203.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1192.55, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1192.55, "10th_percentile": 1192.55, "90th_percentile": 1192.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 8003.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 8003.66, "10th_percentile": 8003.66, "90th_percentile": 8003.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1192.55, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1192.55, "10th_percentile": 1192.55, "90th_percentile": 1192.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 4474.05, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4474.05, "10th_percentile": 4474.05, "90th_percentile": 4474.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1440.66, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1440.66, "10th_percentile": 1440.66, "90th_percentile": 1440.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 5580.15, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5580.15, "10th_percentile": 5580.15, "90th_percentile": 5580.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 1864.85, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 1864.85, "10th_percentile": 1864.85, "90th_percentile": 1864.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 4001.83, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4001.83, "10th_percentile": 4001.83, "90th_percentile": 4001.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 1744.8, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1744.8, "10th_percentile": 1744.8, "90th_percentile": 1744.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 6402.93, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 6402.93, "10th_percentile": 6402.93, "90th_percentile": 6402.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 3921.79, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3921.79, "10th_percentile": 3921.79, "90th_percentile": 3921.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 6402.93, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 6402.93, "10th_percentile": 6402.93, "90th_percentile": 6402.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 4962.27, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4962.27, "10th_percentile": 4962.27, "90th_percentile": 4962.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 5522.53, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 5522.53, "10th_percentile": 5522.53, "90th_percentile": 5522.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 6002.75, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 6002.75, "10th_percentile": 6002.75, "90th_percentile": 6002.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 4001.83, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 4001.83, "10th_percentile": 4001.83, "90th_percentile": 4001.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 5202.38, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 5202.38, "10th_percentile": 5202.38, "90th_percentile": 5202.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 6803.11, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 6803.11, "10th_percentile": 6803.11, "90th_percentile": 6803.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 5042.31, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 5042.31, "10th_percentile": 5042.31, "90th_percentile": 5042.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 7203.29, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 7203.29, "10th_percentile": 7203.29, "90th_percentile": 7203.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 6002.75, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 6002.75, "10th_percentile": 6002.75, "90th_percentile": 6002.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 5140.75, "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": 5140.75, "10th_percentile": 5140.75, "90th_percentile": 5140.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 3793.73, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3793.73, "10th_percentile": 3793.73, "90th_percentile": 3793.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 4217.93, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4217.93, "10th_percentile": 4217.93, "90th_percentile": 4217.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 8003.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 8003.66, "10th_percentile": 8003.66, "90th_percentile": 8003.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $8,003.66 @ 12.5% = $1,000.46 due to $0.00 Claim Price", "median_amount": 1000.46, "10th_percentile": 1000.46, "90th_percentile": 1000.46, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $8,003.66 @ 12.5% = $1,000.46 due to $0.00 Claim Price" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $8,003.66 @ 6.8% = $544.25 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": 544.25, "10th_percentile": 544.25, "90th_percentile": 544.25, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $8,003.66 @ 6.8% = $544.25 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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $8,003.66 @ 6.8% = $544.25 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": 544.25, "10th_percentile": 544.25, "90th_percentile": 544.25, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $8,003.66 @ 6.8% = $544.25 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $8,003.66 @ 6.8% = $544.25 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": 544.25, "10th_percentile": 544.25, "90th_percentile": 544.25, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $8,003.66 @ 6.8% = $544.25 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": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 8003.66, "10th_percentile": 8003.66, "90th_percentile": 8003.66, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8003.66, "10th_percentile": 8003.66, "90th_percentile": 8003.66, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8003.66, "10th_percentile": 8003.66, "90th_percentile": 8003.66, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8003.66, "10th_percentile": 8003.66, "90th_percentile": 8003.66, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8003.66, "10th_percentile": 8003.66, "90th_percentile": 8003.66, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8003.66, "10th_percentile": 8003.66, "90th_percentile": 8003.66, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8003.66, "10th_percentile": 8003.66, "90th_percentile": 8003.66, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "CATH ANGIO BALLN DILAT PTA ULT", "code_information": [ { "code": "SUP-337514", "type": "CDM" }, { "code": "C1725", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 135.81, "maximum": 911.47, "setting": "outpatient", "gross_charge": 911.47, "discounted_cash": 638.03, "payers_information": [ { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 446.62, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 36.66, "10th_percentile": 36.66, "90th_percentile": 36.66, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 480.34, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.36, "10th_percentile": 16.36, "90th_percentile": 16.36, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 911.47, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 911.47, "10th_percentile": 911.47, "90th_percentile": 911.47, "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": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 509.51, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 509.51, "10th_percentile": 509.51, "90th_percentile": 509.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 135.81, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 135.81, "10th_percentile": 135.81, "90th_percentile": 135.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 135.81, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 135.81, "10th_percentile": 135.81, "90th_percentile": 135.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 164.06, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 164.06, "10th_percentile": 164.06, "90th_percentile": 164.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 635.48, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 635.48, "10th_percentile": 635.48, "90th_percentile": 635.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 212.37, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 212.37, "10th_percentile": 212.37, "90th_percentile": 212.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 148.57, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 148.57, "10th_percentile": 148.57, "90th_percentile": 148.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 618.89, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 618.89, "10th_percentile": 618.89, "90th_percentile": 618.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 565.11, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 565.11, "10th_percentile": 565.11, "90th_percentile": 565.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 635.48, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 635.48, "10th_percentile": 635.48, "90th_percentile": 635.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 212.37, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 212.37, "10th_percentile": 212.37, "90th_percentile": 212.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 820.32, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 820.32, "10th_percentile": 820.32, "90th_percentile": 820.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 455.74, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 455.74, "10th_percentile": 455.74, "90th_percentile": 455.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 198.7, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.2, "10th_percentile": 20.2, "90th_percentile": 20.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 729.18, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 729.18, "10th_percentile": 729.18, "90th_percentile": 729.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 729.18, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 729.18, "10th_percentile": 729.18, "90th_percentile": 729.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 565.11, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 565.11, "10th_percentile": 565.11, "90th_percentile": 565.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 628.91, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 628.91, "10th_percentile": 628.91, "90th_percentile": 628.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 683.6, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 683.6, "10th_percentile": 683.6, "90th_percentile": 683.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 455.74, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 455.74, "10th_percentile": 455.74, "90th_percentile": 455.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 592.46, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 592.46, "10th_percentile": 592.46, "90th_percentile": 592.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 774.75, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 774.75, "10th_percentile": 774.75, "90th_percentile": 774.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 574.23, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 574.23, "10th_percentile": 574.23, "90th_percentile": 574.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 820.32, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 820.32, "10th_percentile": 820.32, "90th_percentile": 820.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 683.6, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 683.6, "10th_percentile": 683.6, "90th_percentile": 683.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 585.44, "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": 585.44, "10th_percentile": 585.44, "90th_percentile": 585.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 432.04, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 432.04, "10th_percentile": 432.04, "90th_percentile": 432.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 911.47, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 911.47, "10th_percentile": 911.47, "90th_percentile": 911.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $911.47 @ 12.5% = $113.93 due to $0.00 Claim Price", "median_amount": 113.93, "10th_percentile": 113.93, "90th_percentile": 113.93, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $911.47 @ 12.5% = $113.93 due to $0.00 Claim Price" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $911.47 @ 6.8% = $61.98 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": 61.98, "10th_percentile": 61.98, "90th_percentile": 61.98, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $911.47 @ 6.8% = $61.98 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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $911.47 @ 6.8% = $61.98 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": 61.98, "10th_percentile": 61.98, "90th_percentile": 61.98, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $911.47 @ 6.8% = $61.98 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $911.47 @ 6.8% = $61.98 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": 61.98, "10th_percentile": 61.98, "90th_percentile": 61.98, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $911.47 @ 6.8% = $61.98 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": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 911.47, "10th_percentile": 911.47, "90th_percentile": 911.47, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 911.47, "10th_percentile": 911.47, "90th_percentile": 911.47, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 911.47, "10th_percentile": 911.47, "90th_percentile": 911.47, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 911.47, "10th_percentile": 911.47, "90th_percentile": 911.47, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 911.47, "10th_percentile": 911.47, "90th_percentile": 911.47, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 911.47, "10th_percentile": 911.47, "90th_percentile": 911.47, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 911.47, "10th_percentile": 911.47, "90th_percentile": 911.47, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "CATH ANGIO BALLN DILAT PTA ULT", "code_information": [ { "code": "SUP-337517", "type": "CDM" }, { "code": "C1725", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 135.81, "maximum": 911.47, "setting": "outpatient", "gross_charge": 911.47, "discounted_cash": 638.03, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 480.34, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.36, "10th_percentile": 16.36, "90th_percentile": 16.36, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 585.44, "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": 585.44, "10th_percentile": 585.44, "90th_percentile": 585.44, "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": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 911.47, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 911.47, "10th_percentile": 911.47, "90th_percentile": 911.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 432.04, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 432.04, "10th_percentile": 432.04, "90th_percentile": 432.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 911.47, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 911.47, "10th_percentile": 911.47, "90th_percentile": 911.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 683.6, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 683.6, "10th_percentile": 683.6, "90th_percentile": 683.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 820.32, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 820.32, "10th_percentile": 820.32, "90th_percentile": 820.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 911.47, "10th_percentile": 911.47, "90th_percentile": 911.47, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 911.47, "10th_percentile": 911.47, "90th_percentile": 911.47, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 446.62, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 36.66, "10th_percentile": 36.66, "90th_percentile": 36.66, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 509.51, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 509.51, "10th_percentile": 509.51, "90th_percentile": 509.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 135.81, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 135.81, "10th_percentile": 135.81, "90th_percentile": 135.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 135.81, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 135.81, "10th_percentile": 135.81, "90th_percentile": 135.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 164.06, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 164.06, "10th_percentile": 164.06, "90th_percentile": 164.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 635.48, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 635.48, "10th_percentile": 635.48, "90th_percentile": 635.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 212.37, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 212.37, "10th_percentile": 212.37, "90th_percentile": 212.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 148.57, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 148.57, "10th_percentile": 148.57, "90th_percentile": 148.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 618.89, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 618.89, "10th_percentile": 618.89, "90th_percentile": 618.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 565.11, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 565.11, "10th_percentile": 565.11, "90th_percentile": 565.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 635.48, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 635.48, "10th_percentile": 635.48, "90th_percentile": 635.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 212.37, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 212.37, "10th_percentile": 212.37, "90th_percentile": 212.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 820.32, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 820.32, "10th_percentile": 820.32, "90th_percentile": 820.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 455.74, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 455.74, "10th_percentile": 455.74, "90th_percentile": 455.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 198.7, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.2, "10th_percentile": 20.2, "90th_percentile": 20.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 729.18, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 729.18, "10th_percentile": 729.18, "90th_percentile": 729.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 729.18, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 729.18, "10th_percentile": 729.18, "90th_percentile": 729.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 565.11, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 565.11, "10th_percentile": 565.11, "90th_percentile": 565.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 628.91, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 628.91, "10th_percentile": 628.91, "90th_percentile": 628.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 683.6, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 683.6, "10th_percentile": 683.6, "90th_percentile": 683.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 455.74, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 455.74, "10th_percentile": 455.74, "90th_percentile": 455.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 592.46, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 592.46, "10th_percentile": 592.46, "90th_percentile": 592.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 774.75, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 774.75, "10th_percentile": 774.75, "90th_percentile": 774.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 574.23, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 574.23, "10th_percentile": 574.23, "90th_percentile": 574.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $911.47 @ 12.5% = $113.93 due to $0.00 Claim Price", "median_amount": 113.93, "10th_percentile": 113.93, "90th_percentile": 113.93, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $911.47 @ 12.5% = $113.93 due to $0.00 Claim Price" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $911.47 @ 6.8% = $61.98 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": 61.98, "10th_percentile": 61.98, "90th_percentile": 61.98, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $911.47 @ 6.8% = $61.98 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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $911.47 @ 6.8% = $61.98 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": 61.98, "10th_percentile": 61.98, "90th_percentile": 61.98, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $911.47 @ 6.8% = $61.98 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $911.47 @ 6.8% = $61.98 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": 61.98, "10th_percentile": 61.98, "90th_percentile": 61.98, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $911.47 @ 6.8% = $61.98 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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 911.47, "10th_percentile": 911.47, "90th_percentile": 911.47, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 911.47, "10th_percentile": 911.47, "90th_percentile": 911.47, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 911.47, "10th_percentile": 911.47, "90th_percentile": 911.47, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 911.47, "10th_percentile": 911.47, "90th_percentile": 911.47, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 911.47, "10th_percentile": 911.47, "90th_percentile": 911.47, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "CATH ANGIO BLLN DIL ELITE NANO", "code_information": [ { "code": "SUP-313840", "type": "CDM" }, { "code": "C1725", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 205.11, "maximum": 1376.55, "setting": "outpatient", "gross_charge": 1376.55, "discounted_cash": 963.58, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 725.44, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.36, "10th_percentile": 16.36, "90th_percentile": 16.36, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 652.48, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 652.48, "10th_percentile": 652.48, "90th_percentile": 652.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 884.16, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 884.16, "10th_percentile": 884.16, "90th_percentile": 884.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 867.23, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 867.23, "10th_percentile": 867.23, "90th_percentile": 867.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 894.76, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 894.76, "10th_percentile": 894.76, "90th_percentile": 894.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 1170.07, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 1170.07, "10th_percentile": 1170.07, "90th_percentile": 1170.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 949.82, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 949.82, "10th_percentile": 949.82, "90th_percentile": 949.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 1032.41, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 1032.41, "10th_percentile": 1032.41, "90th_percentile": 1032.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 1032.41, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 1032.41, "10th_percentile": 1032.41, "90th_percentile": 1032.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1376.55, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1376.55, "10th_percentile": 1376.55, "90th_percentile": 1376.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1376.55, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1376.55, "10th_percentile": 1376.55, "90th_percentile": 1376.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 688.28, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 688.28, "10th_percentile": 688.28, "90th_percentile": 688.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 1101.24, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 1101.24, "10th_percentile": 1101.24, "90th_percentile": 1101.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 1238.9, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 1238.9, "10th_percentile": 1238.9, "90th_percentile": 1238.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 853.46, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 853.46, "10th_percentile": 853.46, "90th_percentile": 853.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,376.55 @ 6.8% = $93.61 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": 93.61, "10th_percentile": 93.61, "90th_percentile": 93.61, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,376.55 @ 6.8% = $93.61 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,376.55 @ 6.8% = $93.61 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": 93.61, "10th_percentile": 93.61, "90th_percentile": 93.61, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,376.55 @ 6.8% = $93.61 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": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,376.55 @ 12.5% = $172.07 due to $0.00 Claim Price", "median_amount": 172.07, "10th_percentile": 172.07, "90th_percentile": 172.07, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,376.55 @ 12.5% = $172.07 due to $0.00 Claim Price" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 1376.55, "10th_percentile": 1376.55, "90th_percentile": 1376.55, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1376.55, "10th_percentile": 1376.55, "90th_percentile": 1376.55, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1376.55, "10th_percentile": 1376.55, "90th_percentile": 1376.55, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 674.51, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 36.66, "10th_percentile": 36.66, "90th_percentile": 36.66, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 688.28, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 688.28, "10th_percentile": 688.28, "90th_percentile": 688.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 1238.9, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 1238.9, "10th_percentile": 1238.9, "90th_percentile": 1238.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1101.24, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 1101.24, "10th_percentile": 1101.24, "90th_percentile": 1101.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 853.46, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 853.46, "10th_percentile": 853.46, "90th_percentile": 853.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 959.73, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 959.73, "10th_percentile": 959.73, "90th_percentile": 959.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 959.73, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 959.73, "10th_percentile": 959.73, "90th_percentile": 959.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 320.74, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 320.74, "10th_percentile": 320.74, "90th_percentile": 320.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 320.74, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 320.74, "10th_percentile": 320.74, "90th_percentile": 320.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 205.11, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 205.11, "10th_percentile": 205.11, "90th_percentile": 205.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 205.11, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 205.11, "10th_percentile": 205.11, "90th_percentile": 205.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 300.09, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.2, "10th_percentile": 20.2, "90th_percentile": 20.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 224.38, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% 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 Services; 16.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 934.68, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 934.68, "10th_percentile": 934.68, "90th_percentile": 934.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 769.49, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 769.49, "10th_percentile": 769.49, "90th_percentile": 769.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 247.78, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 247.78, "10th_percentile": 247.78, "90th_percentile": 247.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual 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": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,376.55 @ 6.8% = $93.61 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": 93.61, "10th_percentile": 93.61, "90th_percentile": 93.61, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,376.55 @ 6.8% = $93.61 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 BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1376.55, "10th_percentile": 1376.55, "90th_percentile": 1376.55, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1376.55, "10th_percentile": 1376.55, "90th_percentile": 1376.55, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1376.55, "10th_percentile": 1376.55, "90th_percentile": 1376.55, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1376.55, "10th_percentile": 1376.55, "90th_percentile": 1376.55, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "CATH ANGIO BLLN DIL OTW 6X250M", "code_information": [ { "code": "SUP-340258", "type": "CDM" }, { "code": "C1725", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 187.53, "maximum": 1258.56, "setting": "outpatient", "gross_charge": 1258.56, "discounted_cash": 880.99, "payers_information": [ { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 616.69, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 36.66, "10th_percentile": 36.66, "90th_percentile": 36.66, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 274.37, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.2, "10th_percentile": 20.2, "90th_percentile": 20.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1006.85, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 1006.85, "10th_percentile": 1006.85, "90th_percentile": 1006.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 703.54, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 703.54, "10th_percentile": 703.54, "90th_percentile": 703.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 226.54, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 226.54, "10th_percentile": 226.54, "90th_percentile": 226.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH COMPSYCH", "standard_charge_dollar": 1006.85, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 1006.85, "10th_percentile": 1006.85, "90th_percentile": 1006.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 868.41, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 868.41, "10th_percentile": 868.41, "90th_percentile": 868.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 629.28, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 629.28, "10th_percentile": 629.28, "90th_percentile": 629.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 854.56, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 854.56, "10th_percentile": 854.56, "90th_percentile": 854.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 205.15, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 205.15, "10th_percentile": 205.15, "90th_percentile": 205.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 629.28, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 629.28, "10th_percentile": 629.28, "90th_percentile": 629.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 943.92, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 943.92, "10th_percentile": 943.92, "90th_percentile": 943.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 293.24, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 293.24, "10th_percentile": 293.24, "90th_percentile": 293.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 293.24, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 293.24, "10th_percentile": 293.24, "90th_percentile": 293.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 187.53, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 187.53, "10th_percentile": 187.53, "90th_percentile": 187.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 187.53, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 187.53, "10th_percentile": 187.53, "90th_percentile": 187.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 1132.7, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 1132.7, "10th_percentile": 1132.7, "90th_percentile": 1132.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 877.47, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 877.47, "10th_percentile": 877.47, "90th_percentile": 877.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 877.47, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 877.47, "10th_percentile": 877.47, "90th_percentile": 877.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 780.31, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 780.31, "10th_percentile": 780.31, "90th_percentile": 780.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 780.31, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 780.31, "10th_percentile": 780.31, "90th_percentile": 780.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,258.56 @ 12.5% = $157.32 due to $0.00 Claim Price", "median_amount": 157.32, "10th_percentile": 157.32, "90th_percentile": 157.32, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,258.56 @ 12.5% = $157.32 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,258.56 @ 6.8% = $85.58 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": 85.58, "10th_percentile": 85.58, "90th_percentile": 85.58, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,258.56 @ 6.8% = $85.58 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,258.56 @ 6.8% = $85.58 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": 85.58, "10th_percentile": 85.58, "90th_percentile": 85.58, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,258.56 @ 6.8% = $85.58 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": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,258.56 @ 6.8% = $85.58 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": 85.58, "10th_percentile": 85.58, "90th_percentile": 85.58, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,258.56 @ 6.8% = $85.58 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 BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1258.56, "10th_percentile": 1258.56, "90th_percentile": 1258.56, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1258.56, "10th_percentile": 1258.56, "90th_percentile": 1258.56, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1258.56, "10th_percentile": 1258.56, "90th_percentile": 1258.56, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1258.56, "10th_percentile": 1258.56, "90th_percentile": 1258.56, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 663.26, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.36, "10th_percentile": 16.36, "90th_percentile": 16.36, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 808.37, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 808.37, "10th_percentile": 808.37, "90th_percentile": 808.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 792.89, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 792.89, "10th_percentile": 792.89, "90th_percentile": 792.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1258.56, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1258.56, "10th_percentile": 1258.56, "90th_percentile": 1258.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 596.56, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 596.56, "10th_percentile": 596.56, "90th_percentile": 596.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1258.56, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1258.56, "10th_percentile": 1258.56, "90th_percentile": 1258.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 943.92, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 943.92, "10th_percentile": 943.92, "90th_percentile": 943.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 1069.78, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 1069.78, "10th_percentile": 1069.78, "90th_percentile": 1069.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 818.06, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 818.06, "10th_percentile": 818.06, "90th_percentile": 818.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 1132.7, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 1132.7, "10th_percentile": 1132.7, "90th_percentile": 1132.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 1258.56, "10th_percentile": 1258.56, "90th_percentile": 1258.56, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1258.56, "10th_percentile": 1258.56, "90th_percentile": 1258.56, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1258.56, "10th_percentile": 1258.56, "90th_percentile": 1258.56, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "CATH ANGIO BLLN DIL PTA NC 3.5X210MMX150CM", "code_information": [ { "code": "SUP-354948", "type": "CDM" }, { "code": "C1725", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 205.11, "maximum": 1376.55, "setting": "outpatient", "gross_charge": 1376.55, "discounted_cash": 963.58, "payers_information": [ { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 674.51, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 36.66, "10th_percentile": 36.66, "90th_percentile": 36.66, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 725.44, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.36, "10th_percentile": 16.36, "90th_percentile": 16.36, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1376.55, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1376.55, "10th_percentile": 1376.55, "90th_percentile": 1376.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 769.49, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 769.49, "10th_percentile": 769.49, "90th_percentile": 769.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 205.11, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 205.11, "10th_percentile": 205.11, "90th_percentile": 205.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 205.11, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 205.11, "10th_percentile": 205.11, "90th_percentile": 205.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 247.78, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 247.78, "10th_percentile": 247.78, "90th_percentile": 247.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 959.73, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 959.73, "10th_percentile": 959.73, "90th_percentile": 959.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 320.74, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 320.74, "10th_percentile": 320.74, "90th_percentile": 320.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 853.46, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 853.46, "10th_percentile": 853.46, "90th_percentile": 853.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 934.68, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 934.68, "10th_percentile": 934.68, "90th_percentile": 934.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 224.38, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% 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 Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 959.73, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 959.73, "10th_percentile": 959.73, "90th_percentile": 959.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 320.74, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 320.74, "10th_percentile": 320.74, "90th_percentile": 320.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 1238.9, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 1238.9, "10th_percentile": 1238.9, "90th_percentile": 1238.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 688.28, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 688.28, "10th_percentile": 688.28, "90th_percentile": 688.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 300.09, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.2, "10th_percentile": 20.2, "90th_percentile": 20.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1101.24, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 1101.24, "10th_percentile": 1101.24, "90th_percentile": 1101.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 1101.24, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 1101.24, "10th_percentile": 1101.24, "90th_percentile": 1101.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 853.46, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 853.46, "10th_percentile": 853.46, "90th_percentile": 853.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 949.82, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 949.82, "10th_percentile": 949.82, "90th_percentile": 949.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 1032.41, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 1032.41, "10th_percentile": 1032.41, "90th_percentile": 1032.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 688.28, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 688.28, "10th_percentile": 688.28, "90th_percentile": 688.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 894.76, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 894.76, "10th_percentile": 894.76, "90th_percentile": 894.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 1170.07, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 1170.07, "10th_percentile": 1170.07, "90th_percentile": 1170.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 867.23, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 867.23, "10th_percentile": 867.23, "90th_percentile": 867.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 1238.9, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 1238.9, "10th_percentile": 1238.9, "90th_percentile": 1238.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 1032.41, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 1032.41, "10th_percentile": 1032.41, "90th_percentile": 1032.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 884.16, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 884.16, "10th_percentile": 884.16, "90th_percentile": 884.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 652.48, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 652.48, "10th_percentile": 652.48, "90th_percentile": 652.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1376.55, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1376.55, "10th_percentile": 1376.55, "90th_percentile": 1376.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,376.55 @ 12.5% = $172.07 due to $0.00 Claim Price", "median_amount": 172.07, "10th_percentile": 172.07, "90th_percentile": 172.07, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,376.55 @ 12.5% = $172.07 due to $0.00 Claim Price" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,376.55 @ 6.8% = $93.61 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": 93.61, "10th_percentile": 93.61, "90th_percentile": 93.61, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,376.55 @ 6.8% = $93.61 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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,376.55 @ 6.8% = $93.61 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": 93.61, "10th_percentile": 93.61, "90th_percentile": 93.61, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,376.55 @ 6.8% = $93.61 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,376.55 @ 6.8% = $93.61 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": 93.61, "10th_percentile": 93.61, "90th_percentile": 93.61, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,376.55 @ 6.8% = $93.61 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": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 1376.55, "10th_percentile": 1376.55, "90th_percentile": 1376.55, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1376.55, "10th_percentile": 1376.55, "90th_percentile": 1376.55, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1376.55, "10th_percentile": 1376.55, "90th_percentile": 1376.55, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1376.55, "10th_percentile": 1376.55, "90th_percentile": 1376.55, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1376.55, "10th_percentile": 1376.55, "90th_percentile": 1376.55, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1376.55, "10th_percentile": 1376.55, "90th_percentile": 1376.55, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1376.55, "10th_percentile": 1376.55, "90th_percentile": 1376.55, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "CATH ANGIO BLLN DIL PTA OTW AN", "code_information": [ { "code": "SUP-322638", "type": "CDM" }, { "code": "C1725", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 1318.54, "maximum": 8849.25, "setting": "outpatient", "gross_charge": 8849.25, "discounted_cash": 6194.47, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 4663.55, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.36, "10th_percentile": 16.36, "90th_percentile": 16.36, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 4336.13, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 36.66, "10th_percentile": 36.66, "90th_percentile": 36.66, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 1929.14, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.2, "10th_percentile": 20.2, "90th_percentile": 20.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 8849.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 8849.25, "10th_percentile": 8849.25, "90th_percentile": 8849.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 6636.94, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 6636.94, "10th_percentile": 6636.94, "90th_percentile": 6636.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 7079.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 7079.4, "10th_percentile": 7079.4, "90th_percentile": 7079.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 4946.73, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4946.73, "10th_percentile": 4946.73, "90th_percentile": 4946.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1592.87, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1592.87, "10th_percentile": 1592.87, "90th_percentile": 1592.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 8849.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 8849.25, "10th_percentile": 8849.25, "90th_percentile": 8849.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 7079.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 7079.4, "10th_percentile": 7079.4, "90th_percentile": 7079.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 5683.87, "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": 5683.87, "10th_percentile": 5683.87, "90th_percentile": 5683.87, "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": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 6105.98, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 6105.98, "10th_percentile": 6105.98, "90th_percentile": 6105.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 4194.54, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4194.54, "10th_percentile": 4194.54, "90th_percentile": 4194.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 4424.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4424.63, "10th_percentile": 4424.63, "90th_percentile": 4424.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 6008.64, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6008.64, "10th_percentile": 6008.64, "90th_percentile": 6008.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 5575.03, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 5575.03, "10th_percentile": 5575.03, "90th_percentile": 5575.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 1442.43, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 1442.43, "10th_percentile": 1442.43, "90th_percentile": 1442.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 5752.01, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 5752.01, "10th_percentile": 5752.01, "90th_percentile": 5752.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 7521.86, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 7521.86, "10th_percentile": 7521.86, "90th_percentile": 7521.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 4424.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 4424.63, "10th_percentile": 4424.63, "90th_percentile": 4424.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 6636.94, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 6636.94, "10th_percentile": 6636.94, "90th_percentile": 6636.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 2061.88, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 2061.88, "10th_percentile": 2061.88, "90th_percentile": 2061.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 2061.88, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 2061.88, "10th_percentile": 2061.88, "90th_percentile": 2061.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1318.54, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1318.54, "10th_percentile": 1318.54, "90th_percentile": 1318.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1318.54, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1318.54, "10th_percentile": 1318.54, "90th_percentile": 1318.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 7964.33, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 7964.33, "10th_percentile": 7964.33, "90th_percentile": 7964.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 7964.33, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 7964.33, "10th_percentile": 7964.33, "90th_percentile": 7964.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 6169.7, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6169.7, "10th_percentile": 6169.7, "90th_percentile": 6169.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 6169.7, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6169.7, "10th_percentile": 6169.7, "90th_percentile": 6169.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 5486.54, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5486.54, "10th_percentile": 5486.54, "90th_percentile": 5486.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 5486.54, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5486.54, "10th_percentile": 5486.54, "90th_percentile": 5486.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $8,849.25 @ 12.5% = $1,106.16 due to $0.00 Claim Price", "median_amount": 1106.16, "10th_percentile": 1106.16, "90th_percentile": 1106.16, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $8,849.25 @ 12.5% = $1,106.16 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $8,849.25 @ 6.8% = $601.75 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": 601.75, "10th_percentile": 601.75, "90th_percentile": 601.75, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $8,849.25 @ 6.8% = $601.75 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $8,849.25 @ 6.8% = $601.75 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": 601.75, "10th_percentile": 601.75, "90th_percentile": 601.75, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $8,849.25 @ 6.8% = $601.75 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": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $8,849.25 @ 6.8% = $601.75 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": 601.75, "10th_percentile": 601.75, "90th_percentile": 601.75, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $8,849.25 @ 6.8% = $601.75 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": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 8849.25, "10th_percentile": 8849.25, "90th_percentile": 8849.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8849.25, "10th_percentile": 8849.25, "90th_percentile": 8849.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8849.25, "10th_percentile": 8849.25, "90th_percentile": 8849.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8849.25, "10th_percentile": 8849.25, "90th_percentile": 8849.25, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8849.25, "10th_percentile": 8849.25, "90th_percentile": 8849.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8849.25, "10th_percentile": 8849.25, "90th_percentile": 8849.25, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8849.25, "10th_percentile": 8849.25, "90th_percentile": 8849.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "CATH ANGIO BLLN DIL PTXL PTA O", "code_information": [ { "code": "SUP-310423", "type": "CDM" }, { "code": "C2623", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 1714.1, "maximum": 11504.03, "setting": "outpatient", "gross_charge": 11504.03, "discounted_cash": 8052.82, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 11504.03, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 11504.03, "10th_percentile": 11504.03, "90th_percentile": 11504.03, "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": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1714.1, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1714.1, "10th_percentile": 1714.1, "90th_percentile": 1714.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 2070.73, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2070.73, "10th_percentile": 2070.73, "90th_percentile": 2070.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1714.1, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1714.1, "10th_percentile": 1714.1, "90th_percentile": 1714.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 8020.61, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8020.61, "10th_percentile": 8020.61, "90th_percentile": 8020.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 6430.75, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6430.75, "10th_percentile": 6430.75, "90th_percentile": 6430.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 2680.44, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 2680.44, "10th_percentile": 2680.44, "90th_percentile": 2680.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 7132.5, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7132.5, "10th_percentile": 7132.5, "90th_percentile": 7132.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 7811.24, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7811.24, "10th_percentile": 7811.24, "90th_percentile": 7811.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 1875.16, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 1875.16, "10th_percentile": 1875.16, "90th_percentile": 1875.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 8020.61, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8020.61, "10th_percentile": 8020.61, "90th_percentile": 8020.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 2680.44, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 2680.44, "10th_percentile": 2680.44, "90th_percentile": 2680.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 10353.63, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 10353.63, "10th_percentile": 10353.63, "90th_percentile": 10353.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 5752.02, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5752.02, "10th_percentile": 5752.02, "90th_percentile": 5752.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 2507.88, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2507.88, "10th_percentile": 2507.88, "90th_percentile": 2507.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 9203.22, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 9203.22, "10th_percentile": 9203.22, "90th_percentile": 9203.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 5636.97, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5636.97, "10th_percentile": 5636.97, "90th_percentile": 5636.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 9203.22, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 9203.22, "10th_percentile": 9203.22, "90th_percentile": 9203.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 7132.5, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7132.5, "10th_percentile": 7132.5, "90th_percentile": 7132.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 7937.78, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 7937.78, "10th_percentile": 7937.78, "90th_percentile": 7937.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 8628.02, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 8628.02, "10th_percentile": 8628.02, "90th_percentile": 8628.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 5752.02, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 5752.02, "10th_percentile": 5752.02, "90th_percentile": 5752.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 7477.62, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 7477.62, "10th_percentile": 7477.62, "90th_percentile": 7477.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 9778.43, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 9778.43, "10th_percentile": 9778.43, "90th_percentile": 9778.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 7247.54, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 7247.54, "10th_percentile": 7247.54, "90th_percentile": 7247.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 10353.63, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 10353.63, "10th_percentile": 10353.63, "90th_percentile": 10353.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 8628.02, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 8628.02, "10th_percentile": 8628.02, "90th_percentile": 8628.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 7389.04, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 7389.04, "10th_percentile": 7389.04, "90th_percentile": 7389.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $11,504.03 @ 12.5% = $1,438.00 due to $0.00 Claim Price", "median_amount": 1438.0, "10th_percentile": 1438.0, "90th_percentile": 1438.0, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $11,504.03 @ 12.5% = $1,438.00 due to $0.00 Claim Price" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $11,504.03 @ 6.8% = $782.27 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": 782.27, "10th_percentile": 782.27, "90th_percentile": 782.27, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $11,504.03 @ 6.8% = $782.27 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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $11,504.03 @ 6.8% = $782.27 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": 782.27, "10th_percentile": 782.27, "90th_percentile": 782.27, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $11,504.03 @ 6.8% = $782.27 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $11,504.03 @ 6.8% = $782.27 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": 782.27, "10th_percentile": 782.27, "90th_percentile": 782.27, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $11,504.03 @ 6.8% = $782.27 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": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 11504.03, "10th_percentile": 11504.03, "90th_percentile": 11504.03, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11504.03, "10th_percentile": 11504.03, "90th_percentile": 11504.03, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11504.03, "10th_percentile": 11504.03, "90th_percentile": 11504.03, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11504.03, "10th_percentile": 11504.03, "90th_percentile": 11504.03, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11504.03, "10th_percentile": 11504.03, "90th_percentile": 11504.03, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11504.03, "10th_percentile": 11504.03, "90th_percentile": 11504.03, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11504.03, "10th_percentile": 11504.03, "90th_percentile": 11504.03, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 5452.91, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5452.91, "10th_percentile": 5452.91, "90th_percentile": 5452.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 6062.62, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6062.62, "10th_percentile": 6062.62, "90th_percentile": 6062.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 11504.03, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 11504.03, "10th_percentile": 11504.03, "90th_percentile": 11504.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" } ] } ] }, { "description": "CATH ANGIO BLLN DILTN PTCA RX MINI TREK 1.2X8 MM", "code_information": [ { "code": "SUP-318435", "type": "CDM" }, { "code": "C1725", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 146.5, "maximum": 983.25, "setting": "outpatient", "gross_charge": 983.25, "discounted_cash": 688.27, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 667.63, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 667.63, "10th_percentile": 667.63, "90th_percentile": 667.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 609.62, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 609.62, "10th_percentile": 609.62, "90th_percentile": 609.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 518.17, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.36, "10th_percentile": 16.36, "90th_percentile": 16.36, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 481.79, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 36.66, "10th_percentile": 36.66, "90th_percentile": 36.66, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 214.35, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.2, "10th_percentile": 20.2, "90th_percentile": 20.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 549.64, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 549.64, "10th_percentile": 549.64, "90th_percentile": 549.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 466.06, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 466.06, "10th_percentile": 466.06, "90th_percentile": 466.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 619.45, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 619.45, "10th_percentile": 619.45, "90th_percentile": 619.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 835.76, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 835.76, "10th_percentile": 835.76, "90th_percentile": 835.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 639.11, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 639.11, "10th_percentile": 639.11, "90th_percentile": 639.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 176.99, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 176.99, "10th_percentile": 176.99, "90th_percentile": 176.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 678.44, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 678.44, "10th_percentile": 678.44, "90th_percentile": 678.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 631.54, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 631.54, "10th_percentile": 631.54, "90th_percentile": 631.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 160.27, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 160.27, "10th_percentile": 160.27, "90th_percentile": 160.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 491.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 491.63, "10th_percentile": 491.63, "90th_percentile": 491.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 491.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 491.63, "10th_percentile": 491.63, "90th_percentile": 491.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 786.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 786.6, "10th_percentile": 786.6, "90th_percentile": 786.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 786.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 786.6, "10th_percentile": 786.6, "90th_percentile": 786.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 229.1, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 229.1, "10th_percentile": 229.1, "90th_percentile": 229.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 229.1, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 229.1, "10th_percentile": 229.1, "90th_percentile": 229.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 146.5, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 146.5, "10th_percentile": 146.5, "90th_percentile": 146.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 146.5, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 146.5, "10th_percentile": 146.5, "90th_percentile": 146.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 609.62, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 609.62, "10th_percentile": 609.62, "90th_percentile": 609.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH HFN EPO", "standard_charge_dollar": 737.44, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 737.44, "10th_percentile": 737.44, "90th_percentile": 737.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 737.44, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 737.44, "10th_percentile": 737.44, "90th_percentile": 737.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 685.52, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 685.52, "10th_percentile": 685.52, "90th_percentile": 685.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 685.52, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 685.52, "10th_percentile": 685.52, "90th_percentile": 685.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 884.93, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 884.93, "10th_percentile": 884.93, "90th_percentile": 884.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 884.93, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 884.93, "10th_percentile": 884.93, "90th_percentile": 884.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 983.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 983.25, "10th_percentile": 983.25, "90th_percentile": 983.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 983.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 983.25, "10th_percentile": 983.25, "90th_percentile": 983.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $983.25 @ 12.5% = $122.91 due to $0.00 Claim Price", "median_amount": 122.91, "10th_percentile": 122.91, "90th_percentile": 122.91, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $983.25 @ 12.5% = $122.91 due to $0.00 Claim Price" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $983.25 @ 6.8% = $66.86 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": 66.86, "10th_percentile": 66.86, "90th_percentile": 66.86, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $983.25 @ 6.8% = $66.86 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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $983.25 @ 6.8% = $66.86 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": 66.86, "10th_percentile": 66.86, "90th_percentile": 66.86, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $983.25 @ 6.8% = $66.86 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $983.25 @ 6.8% = $66.86 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": 66.86, "10th_percentile": 66.86, "90th_percentile": 66.86, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $983.25 @ 6.8% = $66.86 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": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 983.25, "10th_percentile": 983.25, "90th_percentile": 983.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 983.25, "10th_percentile": 983.25, "90th_percentile": 983.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 983.25, "10th_percentile": 983.25, "90th_percentile": 983.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 983.25, "10th_percentile": 983.25, "90th_percentile": 983.25, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 983.25, "10th_percentile": 983.25, "90th_percentile": 983.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 983.25, "10th_percentile": 983.25, "90th_percentile": 983.25, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 983.25, "10th_percentile": 983.25, "90th_percentile": 983.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "CATH ANGIO BLLN OCCL HYPERGLID", "code_information": [ { "code": "SUP-100380", "type": "CDM" }, { "code": "C2628", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 1796.14, "maximum": 12054.65, "setting": "outpatient", "gross_charge": 12054.65, "discounted_cash": 8438.25, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 12054.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 12054.65, "10th_percentile": 12054.65, "90th_percentile": 12054.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 6738.55, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6738.55, "10th_percentile": 6738.55, "90th_percentile": 6738.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1796.14, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1796.14, "10th_percentile": 1796.14, "90th_percentile": 1796.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1796.14, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1796.14, "10th_percentile": 1796.14, "90th_percentile": 1796.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 2169.84, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2169.84, "10th_percentile": 2169.84, "90th_percentile": 2169.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 8404.5, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8404.5, "10th_percentile": 8404.5, "90th_percentile": 8404.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 2808.73, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 2808.73, "10th_percentile": 2808.73, "90th_percentile": 2808.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 10849.19, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 10849.19, "10th_percentile": 10849.19, "90th_percentile": 10849.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 6027.33, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6027.33, "10th_percentile": 6027.33, "90th_percentile": 6027.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 2627.91, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2627.91, "10th_percentile": 2627.91, "90th_percentile": 2627.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 9643.72, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 9643.72, "10th_percentile": 9643.72, "90th_percentile": 9643.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 5906.78, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5906.78, "10th_percentile": 5906.78, "90th_percentile": 5906.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 9643.72, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 9643.72, "10th_percentile": 9643.72, "90th_percentile": 9643.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 7473.88, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7473.88, "10th_percentile": 7473.88, "90th_percentile": 7473.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 8317.71, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 8317.71, "10th_percentile": 8317.71, "90th_percentile": 8317.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 9040.99, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 9040.99, "10th_percentile": 9040.99, "90th_percentile": 9040.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 6027.33, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 6027.33, "10th_percentile": 6027.33, "90th_percentile": 6027.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 7835.52, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 7835.52, "10th_percentile": 7835.52, "90th_percentile": 7835.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 10246.45, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 10246.45, "10th_percentile": 10246.45, "90th_percentile": 10246.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 7594.43, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 7594.43, "10th_percentile": 7594.43, "90th_percentile": 7594.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 10849.19, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 10849.19, "10th_percentile": 10849.19, "90th_percentile": 10849.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 9040.99, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 9040.99, "10th_percentile": 9040.99, "90th_percentile": 9040.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 7742.7, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 7742.7, "10th_percentile": 7742.7, "90th_percentile": 7742.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - 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": "DCH UHC CORE", "standard_charge_dollar": 5713.9, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5713.9, "10th_percentile": 5713.9, "90th_percentile": 5713.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 6352.8, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6352.8, "10th_percentile": 6352.8, "90th_percentile": 6352.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 12054.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 12054.65, "10th_percentile": 12054.65, "90th_percentile": 12054.65, "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": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $12,054.65 @ 6.8% = $819.72 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": 819.72, "10th_percentile": 819.72, "90th_percentile": 819.72, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $12,054.65 @ 6.8% = $819.72 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": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $12,054.65 @ 6.8% = $819.72 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": 819.72, "10th_percentile": 819.72, "90th_percentile": 819.72, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $12,054.65 @ 6.8% = $819.72 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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $12,054.65 @ 6.8% = $819.72 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": 819.72, "10th_percentile": 819.72, "90th_percentile": 819.72, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $12,054.65 @ 6.8% = $819.72 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": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $12,054.65 @ 12.5% = $1,506.83 due to $0.00 Claim Price", "median_amount": 1506.83, "10th_percentile": 1506.83, "90th_percentile": 1506.83, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $12,054.65 @ 12.5% = $1,506.83 due to $0.00 Claim Price" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 12054.65, "10th_percentile": 12054.65, "90th_percentile": 12054.65, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 12054.65, "10th_percentile": 12054.65, "90th_percentile": 12054.65, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 12054.65, "10th_percentile": 12054.65, "90th_percentile": 12054.65, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 12054.65, "10th_percentile": 12054.65, "90th_percentile": 12054.65, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 12054.65, "10th_percentile": 12054.65, "90th_percentile": 12054.65, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 12054.65, "10th_percentile": 12054.65, "90th_percentile": 12054.65, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 7473.88, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7473.88, "10th_percentile": 7473.88, "90th_percentile": 7473.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 8185.11, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8185.11, "10th_percentile": 8185.11, "90th_percentile": 8185.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 1964.91, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 1964.91, "10th_percentile": 1964.91, "90th_percentile": 1964.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 8404.5, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8404.5, "10th_percentile": 8404.5, "90th_percentile": 8404.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 2808.73, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 2808.73, "10th_percentile": 2808.73, "90th_percentile": 2808.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 12054.65, "10th_percentile": 12054.65, "90th_percentile": 12054.65, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "CATH ANGIO BLN DIL EC 4X40MMX80CM", "code_information": [ { "code": "SUP-356243", "type": "CDM" }, { "code": "C1725", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 93.76, "maximum": 629.28, "setting": "outpatient", "gross_charge": 629.28, "discounted_cash": 440.5, "payers_information": [ { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 308.35, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 36.66, "10th_percentile": 36.66, "90th_percentile": 36.66, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 331.63, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.36, "10th_percentile": 16.36, "90th_percentile": 16.36, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 534.89, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 534.89, "10th_percentile": 534.89, "90th_percentile": 534.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 409.03, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 409.03, "10th_percentile": 409.03, "90th_percentile": 409.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 298.28, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 298.28, "10th_percentile": 298.28, "90th_percentile": 298.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 404.19, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 404.19, "10th_percentile": 404.19, "90th_percentile": 404.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 396.45, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 396.45, "10th_percentile": 396.45, "90th_percentile": 396.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 137.18, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.2, "10th_percentile": 20.2, "90th_percentile": 20.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 434.2, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 434.2, "10th_percentile": 434.2, "90th_percentile": 434.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 113.27, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 113.27, "10th_percentile": 113.27, "90th_percentile": 113.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 102.57, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 102.57, "10th_percentile": 102.57, "90th_percentile": 102.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 427.28, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 427.28, "10th_percentile": 427.28, "90th_percentile": 427.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 351.77, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 351.77, "10th_percentile": 351.77, "90th_percentile": 351.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 629.28, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 629.28, "10th_percentile": 629.28, "90th_percentile": 629.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 629.28, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 629.28, "10th_percentile": 629.28, "90th_percentile": 629.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 471.96, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 471.96, "10th_percentile": 471.96, "90th_percentile": 471.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 471.96, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 471.96, "10th_percentile": 471.96, "90th_percentile": 471.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 314.64, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 314.64, "10th_percentile": 314.64, "90th_percentile": 314.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 314.64, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 314.64, "10th_percentile": 314.64, "90th_percentile": 314.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 503.42, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 503.42, "10th_percentile": 503.42, "90th_percentile": 503.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 503.42, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 503.42, "10th_percentile": 503.42, "90th_percentile": 503.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 390.15, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 390.15, "10th_percentile": 390.15, "90th_percentile": 390.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 390.15, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 390.15, "10th_percentile": 390.15, "90th_percentile": 390.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 146.62, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 146.62, "10th_percentile": 146.62, "90th_percentile": 146.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 146.62, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 146.62, "10th_percentile": 146.62, "90th_percentile": 146.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 93.76, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 93.76, "10th_percentile": 93.76, "90th_percentile": 93.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 93.76, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 93.76, "10th_percentile": 93.76, "90th_percentile": 93.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 438.73, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 438.73, "10th_percentile": 438.73, "90th_percentile": 438.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 438.73, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 438.73, "10th_percentile": 438.73, "90th_percentile": 438.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 566.35, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 566.35, "10th_percentile": 566.35, "90th_percentile": 566.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 566.35, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 566.35, "10th_percentile": 566.35, "90th_percentile": 566.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $629.28 @ 12.5% = $78.66 due to $0.00 Claim Price", "median_amount": 78.66, "10th_percentile": 78.66, "90th_percentile": 78.66, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $629.28 @ 12.5% = $78.66 due to $0.00 Claim Price" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $629.28 @ 6.8% = $42.79 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": 42.79, "10th_percentile": 42.79, "90th_percentile": 42.79, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $629.28 @ 6.8% = $42.79 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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $629.28 @ 6.8% = $42.79 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": 42.79, "10th_percentile": 42.79, "90th_percentile": 42.79, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $629.28 @ 6.8% = $42.79 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $629.28 @ 6.8% = $42.79 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": 42.79, "10th_percentile": 42.79, "90th_percentile": 42.79, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $629.28 @ 6.8% = $42.79 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": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 629.28, "10th_percentile": 629.28, "90th_percentile": 629.28, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 629.28, "10th_percentile": 629.28, "90th_percentile": 629.28, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 629.28, "10th_percentile": 629.28, "90th_percentile": 629.28, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 629.28, "10th_percentile": 629.28, "90th_percentile": 629.28, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 629.28, "10th_percentile": 629.28, "90th_percentile": 629.28, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 629.28, "10th_percentile": 629.28, "90th_percentile": 629.28, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 629.28, "10th_percentile": 629.28, "90th_percentile": 629.28, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "CATH ANGIO BLN DIL EC 5X20MMX80CM", "code_information": [ { "code": "SUP-356246", "type": "CDM" }, { "code": "C1725", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 93.76, "maximum": 629.28, "setting": "outpatient", "gross_charge": 629.28, "discounted_cash": 440.5, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 331.63, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.36, "10th_percentile": 16.36, "90th_percentile": 16.36, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 308.35, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 36.66, "10th_percentile": 36.66, "90th_percentile": 36.66, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 396.45, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 396.45, "10th_percentile": 396.45, "90th_percentile": 396.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 534.89, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 534.89, "10th_percentile": 534.89, "90th_percentile": 534.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 409.03, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 409.03, "10th_percentile": 409.03, "90th_percentile": 409.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 434.2, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 434.2, "10th_percentile": 434.2, "90th_percentile": 434.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 298.28, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 298.28, "10th_percentile": 298.28, "90th_percentile": 298.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 404.19, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 404.19, "10th_percentile": 404.19, "90th_percentile": 404.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 137.18, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.2, "10th_percentile": 20.2, "90th_percentile": 20.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 351.77, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 351.77, "10th_percentile": 351.77, "90th_percentile": 351.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 113.27, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 113.27, "10th_percentile": 113.27, "90th_percentile": 113.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 427.28, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 427.28, "10th_percentile": 427.28, "90th_percentile": 427.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 102.57, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 102.57, "10th_percentile": 102.57, "90th_percentile": 102.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 471.96, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 471.96, "10th_percentile": 471.96, "90th_percentile": 471.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 471.96, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 471.96, "10th_percentile": 471.96, "90th_percentile": 471.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 314.64, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 314.64, "10th_percentile": 314.64, "90th_percentile": 314.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 314.64, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 314.64, "10th_percentile": 314.64, "90th_percentile": 314.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 503.42, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 503.42, "10th_percentile": 503.42, "90th_percentile": 503.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 503.42, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 503.42, "10th_percentile": 503.42, "90th_percentile": 503.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 629.28, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 629.28, "10th_percentile": 629.28, "90th_percentile": 629.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 629.28, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 629.28, "10th_percentile": 629.28, "90th_percentile": 629.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 390.15, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 390.15, "10th_percentile": 390.15, "90th_percentile": 390.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 390.15, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 390.15, "10th_percentile": 390.15, "90th_percentile": 390.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 93.76, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 93.76, "10th_percentile": 93.76, "90th_percentile": 93.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 93.76, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 93.76, "10th_percentile": 93.76, "90th_percentile": 93.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 146.62, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 146.62, "10th_percentile": 146.62, "90th_percentile": 146.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 146.62, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 146.62, "10th_percentile": 146.62, "90th_percentile": 146.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 566.35, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 566.35, "10th_percentile": 566.35, "90th_percentile": 566.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 566.35, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 566.35, "10th_percentile": 566.35, "90th_percentile": 566.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 438.73, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 438.73, "10th_percentile": 438.73, "90th_percentile": 438.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 438.73, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 438.73, "10th_percentile": 438.73, "90th_percentile": 438.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $629.28 @ 12.5% = $78.66 due to $0.00 Claim Price", "median_amount": 78.66, "10th_percentile": 78.66, "90th_percentile": 78.66, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $629.28 @ 12.5% = $78.66 due to $0.00 Claim Price" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $629.28 @ 6.8% = $42.79 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": 42.79, "10th_percentile": 42.79, "90th_percentile": 42.79, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $629.28 @ 6.8% = $42.79 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": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $629.28 @ 6.8% = $42.79 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": 42.79, "10th_percentile": 42.79, "90th_percentile": 42.79, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $629.28 @ 6.8% = $42.79 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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $629.28 @ 6.8% = $42.79 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": 42.79, "10th_percentile": 42.79, "90th_percentile": 42.79, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $629.28 @ 6.8% = $42.79 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": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 629.28, "10th_percentile": 629.28, "90th_percentile": 629.28, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 629.28, "10th_percentile": 629.28, "90th_percentile": 629.28, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 629.28, "10th_percentile": 629.28, "90th_percentile": 629.28, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 629.28, "10th_percentile": 629.28, "90th_percentile": 629.28, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 629.28, "10th_percentile": 629.28, "90th_percentile": 629.28, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 629.28, "10th_percentile": 629.28, "90th_percentile": 629.28, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 629.28, "10th_percentile": 629.28, "90th_percentile": 629.28, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "CATH ANGIO BLN DIL EC 9X60MMX80CM", "code_information": [ { "code": "SUP-354968", "type": "CDM" }, { "code": "C1725", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 93.76, "maximum": 629.28, "setting": "outpatient", "gross_charge": 629.28, "discounted_cash": 440.5, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 331.63, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.36, "10th_percentile": 16.36, "90th_percentile": 16.36, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 298.28, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 298.28, "10th_percentile": 298.28, "90th_percentile": 298.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 404.19, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 404.19, "10th_percentile": 404.19, "90th_percentile": 404.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 396.45, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 396.45, "10th_percentile": 396.45, "90th_percentile": 396.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 534.89, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 534.89, "10th_percentile": 534.89, "90th_percentile": 534.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 409.03, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 409.03, "10th_percentile": 409.03, "90th_percentile": 409.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 566.35, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 566.35, "10th_percentile": 566.35, "90th_percentile": 566.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 471.96, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 471.96, "10th_percentile": 471.96, "90th_percentile": 471.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 629.28, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 629.28, "10th_percentile": 629.28, "90th_percentile": 629.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 629.28, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 629.28, "10th_percentile": 629.28, "90th_percentile": 629.28, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 629.28, "10th_percentile": 629.28, "90th_percentile": 629.28, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 629.28, "10th_percentile": 629.28, "90th_percentile": 629.28, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 629.28, "10th_percentile": 629.28, "90th_percentile": 629.28, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 308.35, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 36.66, "10th_percentile": 36.66, "90th_percentile": 36.66, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 434.2, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 434.2, "10th_percentile": 434.2, "90th_percentile": 434.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 137.18, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.2, "10th_percentile": 20.2, "90th_percentile": 20.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 351.77, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 351.77, "10th_percentile": 351.77, "90th_percentile": 351.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 113.27, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 113.27, "10th_percentile": 113.27, "90th_percentile": 113.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 427.28, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 427.28, "10th_percentile": 427.28, "90th_percentile": 427.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 102.57, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 102.57, "10th_percentile": 102.57, "90th_percentile": 102.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 471.96, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 471.96, "10th_percentile": 471.96, "90th_percentile": 471.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 314.64, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 314.64, "10th_percentile": 314.64, "90th_percentile": 314.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 314.64, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 314.64, "10th_percentile": 314.64, "90th_percentile": 314.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 503.42, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 503.42, "10th_percentile": 503.42, "90th_percentile": 503.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 503.42, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 503.42, "10th_percentile": 503.42, "90th_percentile": 503.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 390.15, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 390.15, "10th_percentile": 390.15, "90th_percentile": 390.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 390.15, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 390.15, "10th_percentile": 390.15, "90th_percentile": 390.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 93.76, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 93.76, "10th_percentile": 93.76, "90th_percentile": 93.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 93.76, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 93.76, "10th_percentile": 93.76, "90th_percentile": 93.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 146.62, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 146.62, "10th_percentile": 146.62, "90th_percentile": 146.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 146.62, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 146.62, "10th_percentile": 146.62, "90th_percentile": 146.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 566.35, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 566.35, "10th_percentile": 566.35, "90th_percentile": 566.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 438.73, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 438.73, "10th_percentile": 438.73, "90th_percentile": 438.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 438.73, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 438.73, "10th_percentile": 438.73, "90th_percentile": 438.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $629.28 @ 12.5% = $78.66 due to $0.00 Claim Price", "median_amount": 78.66, "10th_percentile": 78.66, "90th_percentile": 78.66, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $629.28 @ 12.5% = $78.66 due to $0.00 Claim Price" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $629.28 @ 6.8% = $42.79 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": 42.79, "10th_percentile": 42.79, "90th_percentile": 42.79, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $629.28 @ 6.8% = $42.79 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": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $629.28 @ 6.8% = $42.79 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": 42.79, "10th_percentile": 42.79, "90th_percentile": 42.79, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $629.28 @ 6.8% = $42.79 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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $629.28 @ 6.8% = $42.79 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": 42.79, "10th_percentile": 42.79, "90th_percentile": 42.79, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $629.28 @ 6.8% = $42.79 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 BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 629.28, "10th_percentile": 629.28, "90th_percentile": 629.28, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 629.28, "10th_percentile": 629.28, "90th_percentile": 629.28, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 629.28, "10th_percentile": 629.28, "90th_percentile": 629.28, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 629.28, "10th_percentile": 629.28, "90th_percentile": 629.28, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "CATH ANGIO BLN DIL NC 5X80MMX150CM", "code_information": [ { "code": "SUP-354950", "type": "CDM" }, { "code": "C1725", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 205.11, "maximum": 1376.55, "setting": "outpatient", "gross_charge": 1376.55, "discounted_cash": 963.58, "payers_information": [ { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 674.51, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 36.66, "10th_percentile": 36.66, "90th_percentile": 36.66, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1376.55, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1376.55, "10th_percentile": 1376.55, "90th_percentile": 1376.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 205.11, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 205.11, "10th_percentile": 205.11, "90th_percentile": 205.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 205.11, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 205.11, "10th_percentile": 205.11, "90th_percentile": 205.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 769.49, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 769.49, "10th_percentile": 769.49, "90th_percentile": 769.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 247.78, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 247.78, "10th_percentile": 247.78, "90th_percentile": 247.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 959.73, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 959.73, "10th_percentile": 959.73, "90th_percentile": 959.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 320.74, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 320.74, "10th_percentile": 320.74, "90th_percentile": 320.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 224.38, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% 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 Services; 16.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 934.68, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 934.68, "10th_percentile": 934.68, "90th_percentile": 934.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 853.46, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 853.46, "10th_percentile": 853.46, "90th_percentile": 853.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 959.73, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 959.73, "10th_percentile": 959.73, "90th_percentile": 959.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 320.74, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 320.74, "10th_percentile": 320.74, "90th_percentile": 320.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 1238.9, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 1238.9, "10th_percentile": 1238.9, "90th_percentile": 1238.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 688.28, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 688.28, "10th_percentile": 688.28, "90th_percentile": 688.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 300.09, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.2, "10th_percentile": 20.2, "90th_percentile": 20.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1101.24, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 1101.24, "10th_percentile": 1101.24, "90th_percentile": 1101.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 1101.24, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 1101.24, "10th_percentile": 1101.24, "90th_percentile": 1101.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 853.46, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 853.46, "10th_percentile": 853.46, "90th_percentile": 853.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 949.82, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 949.82, "10th_percentile": 949.82, "90th_percentile": 949.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 1032.41, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 1032.41, "10th_percentile": 1032.41, "90th_percentile": 1032.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 688.28, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 688.28, "10th_percentile": 688.28, "90th_percentile": 688.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 894.76, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 894.76, "10th_percentile": 894.76, "90th_percentile": 894.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 1170.07, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 1170.07, "10th_percentile": 1170.07, "90th_percentile": 1170.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 867.23, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 867.23, "10th_percentile": 867.23, "90th_percentile": 867.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 1238.9, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 1238.9, "10th_percentile": 1238.9, "90th_percentile": 1238.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 1032.41, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 1032.41, "10th_percentile": 1032.41, "90th_percentile": 1032.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 884.16, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 884.16, "10th_percentile": 884.16, "90th_percentile": 884.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,376.55 @ 12.5% = $172.07 due to $0.00 Claim Price", "median_amount": 172.07, "10th_percentile": 172.07, "90th_percentile": 172.07, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,376.55 @ 12.5% = $172.07 due to $0.00 Claim Price" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,376.55 @ 6.8% = $93.61 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": 93.61, "10th_percentile": 93.61, "90th_percentile": 93.61, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,376.55 @ 6.8% = $93.61 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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,376.55 @ 6.8% = $93.61 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": 93.61, "10th_percentile": 93.61, "90th_percentile": 93.61, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,376.55 @ 6.8% = $93.61 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,376.55 @ 6.8% = $93.61 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": 93.61, "10th_percentile": 93.61, "90th_percentile": 93.61, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,376.55 @ 6.8% = $93.61 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": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 1376.55, "10th_percentile": 1376.55, "90th_percentile": 1376.55, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1376.55, "10th_percentile": 1376.55, "90th_percentile": 1376.55, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1376.55, "10th_percentile": 1376.55, "90th_percentile": 1376.55, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1376.55, "10th_percentile": 1376.55, "90th_percentile": 1376.55, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1376.55, "10th_percentile": 1376.55, "90th_percentile": 1376.55, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1376.55, "10th_percentile": 1376.55, "90th_percentile": 1376.55, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1376.55, "10th_percentile": 1376.55, "90th_percentile": 1376.55, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 725.44, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.36, "10th_percentile": 16.36, "90th_percentile": 16.36, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1376.55, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1376.55, "10th_percentile": 1376.55, "90th_percentile": 1376.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 652.48, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 652.48, "10th_percentile": 652.48, "90th_percentile": 652.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "CATH ANGIO BLN DIL PTA NANOCRS 4X120MMX150CM", "code_information": [ { "code": "SUP-356261", "type": "CDM" }, { "code": "C1725", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 205.11, "maximum": 1376.55, "setting": "outpatient", "gross_charge": 1376.55, "discounted_cash": 963.58, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 725.44, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.36, "10th_percentile": 16.36, "90th_percentile": 16.36, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 674.51, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 36.66, "10th_percentile": 36.66, "90th_percentile": 36.66, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 1032.41, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 1032.41, "10th_percentile": 1032.41, "90th_percentile": 1032.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 1032.41, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 1032.41, "10th_percentile": 1032.41, "90th_percentile": 1032.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1376.55, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1376.55, "10th_percentile": 1376.55, "90th_percentile": 1376.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1376.55, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1376.55, "10th_percentile": 1376.55, "90th_percentile": 1376.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 688.28, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 688.28, "10th_percentile": 688.28, "90th_percentile": 688.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 688.28, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 688.28, "10th_percentile": 688.28, "90th_percentile": 688.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 1238.9, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 1238.9, "10th_percentile": 1238.9, "90th_percentile": 1238.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 1238.9, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 1238.9, "10th_percentile": 1238.9, "90th_percentile": 1238.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 1101.24, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 1101.24, "10th_percentile": 1101.24, "90th_percentile": 1101.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1101.24, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 1101.24, "10th_percentile": 1101.24, "90th_percentile": 1101.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 853.46, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 853.46, "10th_percentile": 853.46, "90th_percentile": 853.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 853.46, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 853.46, "10th_percentile": 853.46, "90th_percentile": 853.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 959.73, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 959.73, "10th_percentile": 959.73, "90th_percentile": 959.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 959.73, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 959.73, "10th_percentile": 959.73, "90th_percentile": 959.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 320.74, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 320.74, "10th_percentile": 320.74, "90th_percentile": 320.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 320.74, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 320.74, "10th_percentile": 320.74, "90th_percentile": 320.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 205.11, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 205.11, "10th_percentile": 205.11, "90th_percentile": 205.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 205.11, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 205.11, "10th_percentile": 205.11, "90th_percentile": 205.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 867.23, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 867.23, "10th_percentile": 867.23, "90th_percentile": 867.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 652.48, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 652.48, "10th_percentile": 652.48, "90th_percentile": 652.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 894.76, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 894.76, "10th_percentile": 894.76, "90th_percentile": 894.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 1170.07, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 1170.07, "10th_percentile": 1170.07, "90th_percentile": 1170.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 884.16, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 884.16, "10th_percentile": 884.16, "90th_percentile": 884.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 949.82, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 949.82, "10th_percentile": 949.82, "90th_percentile": 949.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 300.09, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.2, "10th_percentile": 20.2, "90th_percentile": 20.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 224.38, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% 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 Services; 16.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 934.68, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 934.68, "10th_percentile": 934.68, "90th_percentile": 934.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 769.49, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 769.49, "10th_percentile": 769.49, "90th_percentile": 769.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 247.78, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 247.78, "10th_percentile": 247.78, "90th_percentile": 247.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,376.55 @ 12.5% = $172.07 due to $0.00 Claim Price", "median_amount": 172.07, "10th_percentile": 172.07, "90th_percentile": 172.07, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,376.55 @ 12.5% = $172.07 due to $0.00 Claim Price" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,376.55 @ 6.8% = $93.61 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": 93.61, "10th_percentile": 93.61, "90th_percentile": 93.61, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,376.55 @ 6.8% = $93.61 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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,376.55 @ 6.8% = $93.61 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": 93.61, "10th_percentile": 93.61, "90th_percentile": 93.61, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,376.55 @ 6.8% = $93.61 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": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,376.55 @ 6.8% = $93.61 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": 93.61, "10th_percentile": 93.61, "90th_percentile": 93.61, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,376.55 @ 6.8% = $93.61 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": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 1376.55, "10th_percentile": 1376.55, "90th_percentile": 1376.55, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1376.55, "10th_percentile": 1376.55, "90th_percentile": 1376.55, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1376.55, "10th_percentile": 1376.55, "90th_percentile": 1376.55, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1376.55, "10th_percentile": 1376.55, "90th_percentile": 1376.55, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1376.55, "10th_percentile": 1376.55, "90th_percentile": 1376.55, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1376.55, "10th_percentile": 1376.55, "90th_percentile": 1376.55, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1376.55, "10th_percentile": 1376.55, "90th_percentile": 1376.55, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "CATH ANGIO BLN DIL SCRG PTA OT", "code_information": [ { "code": "SUP-333884", "type": "CDM" }, { "code": "C1725", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 1574.92, "maximum": 10569.94, "setting": "outpatient", "gross_charge": 10569.94, "discounted_cash": 7398.96, "payers_information": [ { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 5179.27, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 36.66, "10th_percentile": 36.66, "90th_percentile": 36.66, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 5570.36, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.36, "10th_percentile": 16.36, "90th_percentile": 16.36, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 7369.36, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7369.36, "10th_percentile": 7369.36, "90th_percentile": 7369.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1902.59, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1902.59, "10th_percentile": 1902.59, "90th_percentile": 1902.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 2462.8, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 2462.8, "10th_percentile": 2462.8, "90th_percentile": 2462.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 5908.6, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5908.6, "10th_percentile": 5908.6, "90th_percentile": 5908.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1574.92, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1574.92, "10th_percentile": 1574.92, "90th_percentile": 1574.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1574.92, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1574.92, "10th_percentile": 1574.92, "90th_percentile": 1574.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 9512.95, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 9512.95, "10th_percentile": 9512.95, "90th_percentile": 9512.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 9512.95, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 9512.95, "10th_percentile": 9512.95, "90th_percentile": 9512.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 6553.36, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6553.36, "10th_percentile": 6553.36, "90th_percentile": 6553.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 6553.36, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6553.36, "10th_percentile": 6553.36, "90th_percentile": 6553.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH HFN PPO", "standard_charge_dollar": 8984.45, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 8984.45, "10th_percentile": 8984.45, "90th_percentile": 8984.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 6870.46, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 6870.46, "10th_percentile": 6870.46, "90th_percentile": 6870.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 5284.97, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 5284.97, "10th_percentile": 5284.97, "90th_percentile": 5284.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 7927.46, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 7927.46, "10th_percentile": 7927.46, "90th_percentile": 7927.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 2304.25, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.2, "10th_percentile": 20.2, "90th_percentile": 20.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 10569.94, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 10569.94, "10th_percentile": 10569.94, "90th_percentile": 10569.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 8455.95, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 8455.95, "10th_percentile": 8455.95, "90th_percentile": 8455.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 2462.8, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 2462.8, "10th_percentile": 2462.8, "90th_percentile": 2462.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 6789.07, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 6789.07, "10th_percentile": 6789.07, "90th_percentile": 6789.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - 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": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 8455.95, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 8455.95, "10th_percentile": 8455.95, "90th_percentile": 8455.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 7369.36, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7369.36, "10th_percentile": 7369.36, "90th_percentile": 7369.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 5284.97, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5284.97, "10th_percentile": 5284.97, "90th_percentile": 5284.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 1722.9, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 1722.9, "10th_percentile": 1722.9, "90th_percentile": 1722.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 5010.15, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5010.15, "10th_percentile": 5010.15, "90th_percentile": 5010.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 7293.26, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 7293.26, "10th_percentile": 7293.26, "90th_percentile": 7293.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 7176.99, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7176.99, "10th_percentile": 7176.99, "90th_percentile": 7176.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 6659.06, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 6659.06, "10th_percentile": 6659.06, "90th_percentile": 6659.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 10569.94, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 10569.94, "10th_percentile": 10569.94, "90th_percentile": 10569.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 7927.46, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 7927.46, "10th_percentile": 7927.46, "90th_percentile": 7927.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $10,569.94 @ 12.5% = $1,321.24 due to $0.00 Claim Price", "median_amount": 1321.24, "10th_percentile": 1321.24, "90th_percentile": 1321.24, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $10,569.94 @ 12.5% = $1,321.24 due to $0.00 Claim Price" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $10,569.94 @ 6.8% = $718.76 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": 718.76, "10th_percentile": 718.76, "90th_percentile": 718.76, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $10,569.94 @ 6.8% = $718.76 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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $10,569.94 @ 6.8% = $718.76 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": 718.76, "10th_percentile": 718.76, "90th_percentile": 718.76, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $10,569.94 @ 6.8% = $718.76 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $10,569.94 @ 6.8% = $718.76 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": 718.76, "10th_percentile": 718.76, "90th_percentile": 718.76, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $10,569.94 @ 6.8% = $718.76 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": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 10569.94, "10th_percentile": 10569.94, "90th_percentile": 10569.94, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 10569.94, "10th_percentile": 10569.94, "90th_percentile": 10569.94, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 10569.94, "10th_percentile": 10569.94, "90th_percentile": 10569.94, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 10569.94, "10th_percentile": 10569.94, "90th_percentile": 10569.94, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 10569.94, "10th_percentile": 10569.94, "90th_percentile": 10569.94, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 10569.94, "10th_percentile": 10569.94, "90th_percentile": 10569.94, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 10569.94, "10th_percentile": 10569.94, "90th_percentile": 10569.94, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "CATH ANGIO DIAG PIG SH NB IMP", "code_information": [ { "code": "SUP-313582", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 19.23, "maximum": 117.99, "setting": "outpatient", "gross_charge": 117.99, "discounted_cash": 82.59, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 73.15, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 73.15, "10th_percentile": 73.15, "90th_percentile": 73.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 106.19, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 106.19, "10th_percentile": 106.19, "90th_percentile": 106.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 42.52, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 42.52, "10th_percentile": 42.52, "90th_percentile": 42.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 19.23, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 19.23, "10th_percentile": 19.23, "90th_percentile": 19.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 82.26, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 82.26, "10th_percentile": 82.26, "90th_percentile": 82.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 80.12, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 80.12, "10th_percentile": 80.12, "90th_percentile": 80.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 117.99, "10th_percentile": 117.99, "90th_percentile": 117.99, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 117.99, "10th_percentile": 117.99, "90th_percentile": 117.99, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 117.99, "10th_percentile": 117.99, "90th_percentile": 117.99, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 73.15, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 73.15, "10th_percentile": 73.15, "90th_percentile": 73.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 34.03, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 34.03, "10th_percentile": 34.03, "90th_percentile": 34.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 82.26, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 82.26, "10th_percentile": 82.26, "90th_percentile": 82.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 33.37, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 33.37, "10th_percentile": 33.37, "90th_percentile": 33.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 65.96, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 42.52, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 42.52, "10th_percentile": 42.52, "90th_percentile": 42.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 33.04, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 33.04, "10th_percentile": 33.04, "90th_percentile": 33.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 106.19, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 106.19, "10th_percentile": 106.19, "90th_percentile": 106.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 59.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 59.0, "10th_percentile": 59.0, "90th_percentile": 59.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 76.69, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 76.69, "10th_percentile": 76.69, "90th_percentile": 76.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 88.49, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 88.49, "10th_percentile": 88.49, "90th_percentile": 88.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 100.29, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 100.29, "10th_percentile": 100.29, "90th_percentile": 100.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 117.99, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 117.99, "10th_percentile": 117.99, "90th_percentile": 117.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 94.39, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 94.39, "10th_percentile": 94.39, "90th_percentile": 94.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 55.93, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 55.93, "10th_percentile": 55.93, "90th_percentile": 55.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 62.18, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 62.18, "10th_percentile": 62.18, "90th_percentile": 62.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 117.99, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 117.99, "10th_percentile": 117.99, "90th_percentile": 117.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 75.78, "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": 75.78, "10th_percentile": 75.78, "90th_percentile": 75.78, "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": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 88.49, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 88.49, "10th_percentile": 88.49, "90th_percentile": 88.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 25.72, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 25.72, "10th_percentile": 25.72, "90th_percentile": 25.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 94.39, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 94.39, "10th_percentile": 94.39, "90th_percentile": 94.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 57.82, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 57.82, "10th_percentile": 57.82, "90th_percentile": 57.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 59.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 59.0, "10th_percentile": 59.0, "90th_percentile": 59.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 81.41, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 81.41, "10th_percentile": 81.41, "90th_percentile": 81.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 74.33, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 74.33, "10th_percentile": 74.33, "90th_percentile": 74.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 117.99, "10th_percentile": 117.99, "90th_percentile": 117.99, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 117.99, "10th_percentile": 117.99, "90th_percentile": 117.99, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 117.99, "10th_percentile": 117.99, "90th_percentile": 117.99, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 117.99, "10th_percentile": 117.99, "90th_percentile": 117.99, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 117.99, "10th_percentile": 117.99, "90th_percentile": 117.99, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 117.99, "10th_percentile": 117.99, "90th_percentile": 117.99, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 117.99, "10th_percentile": 117.99, "90th_percentile": 117.99, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 117.99, "10th_percentile": 117.99, "90th_percentile": 117.99, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "CATH ANGIO DIAG 3DRC INFIN 5FRX100CM", "code_information": [ { "code": "SUP-142970", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 22.44, "maximum": 137.66, "setting": "outpatient", "gross_charge": 137.66, "discounted_cash": 96.36, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 39.7, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 39.7, "10th_percentile": 39.7, "90th_percentile": 39.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 38.54, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 38.54, "10th_percentile": 38.54, "90th_percentile": 38.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 49.61, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 76.95, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 76.95, "10th_percentile": 76.95, "90th_percentile": 76.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 38.93, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 38.93, "10th_percentile": 38.93, "90th_percentile": 38.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 95.98, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 95.98, "10th_percentile": 95.98, "90th_percentile": 95.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 85.35, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 85.35, "10th_percentile": 85.35, "90th_percentile": 85.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 85.35, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 85.35, "10th_percentile": 85.35, "90th_percentile": 85.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 123.89, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 123.89, "10th_percentile": 123.89, "90th_percentile": 123.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 123.89, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 123.89, "10th_percentile": 123.89, "90th_percentile": 123.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 68.83, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 89.48, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 89.48, "10th_percentile": 89.48, "90th_percentile": 89.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 103.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 103.25, "10th_percentile": 103.25, "90th_percentile": 103.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 117.01, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 117.01, "10th_percentile": 117.01, "90th_percentile": 117.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 49.61, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 86.73, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 86.73, "10th_percentile": 86.73, "90th_percentile": 86.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 30.01, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 30.01, "10th_percentile": 30.01, "90th_percentile": 30.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 67.45, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 67.45, "10th_percentile": 67.45, "90th_percentile": 67.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 110.13, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 110.13, "10th_percentile": 110.13, "90th_percentile": 110.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 68.83, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 22.44, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 22.44, "10th_percentile": 22.44, "90th_percentile": 22.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 110.13, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 110.13, "10th_percentile": 110.13, "90th_percentile": 110.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 95.98, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 95.98, "10th_percentile": 95.98, "90th_percentile": 95.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 94.99, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 94.99, "10th_percentile": 94.99, "90th_percentile": 94.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 93.47, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 93.47, "10th_percentile": 93.47, "90th_percentile": 93.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 137.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 103.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 103.25, "10th_percentile": 103.25, "90th_percentile": 103.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 88.42, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 88.42, "10th_percentile": 88.42, "90th_percentile": 88.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 137.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 72.55, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 72.55, "10th_percentile": 72.55, "90th_percentile": 72.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 65.25, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 65.25, "10th_percentile": 65.25, "90th_percentile": 65.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "description": "CATH ANGIO DIAG 6 HOLE STRT PI", "code_information": [ { "code": "SUP-340796", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 11.22, "maximum": 68.83, "setting": "outpatient", "gross_charge": 68.83, "discounted_cash": 48.18, "payers_information": [ { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 42.67, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 42.67, "10th_percentile": 42.67, "90th_percentile": 42.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 61.95, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 61.95, "10th_percentile": 61.95, "90th_percentile": 61.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 34.42, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 34.42, "10th_percentile": 34.42, "90th_percentile": 34.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 44.74, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 44.74, "10th_percentile": 44.74, "90th_percentile": 44.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 51.62, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 51.62, "10th_percentile": 51.62, "90th_percentile": 51.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 58.51, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 58.51, "10th_percentile": 58.51, "90th_percentile": 58.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 68.83, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 55.06, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 55.06, "10th_percentile": 55.06, "90th_percentile": 55.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 32.63, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 32.63, "10th_percentile": 32.63, "90th_percentile": 32.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 36.27, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 36.27, "10th_percentile": 36.27, "90th_percentile": 36.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 68.83, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 44.21, "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": 44.21, "10th_percentile": 44.21, "90th_percentile": 44.21, "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": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 51.62, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 51.62, "10th_percentile": 51.62, "90th_percentile": 51.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 33.73, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 33.73, "10th_percentile": 33.73, "90th_percentile": 33.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 47.49, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 47.49, "10th_percentile": 47.49, "90th_percentile": 47.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 43.36, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 43.36, "10th_percentile": 43.36, "90th_percentile": 43.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "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": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 19.85, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19.85, "10th_percentile": 19.85, "90th_percentile": 19.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 19.27, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19.27, "10th_percentile": 19.27, "90th_percentile": 19.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 24.81, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 24.81, "10th_percentile": 24.81, "90th_percentile": 24.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 38.48, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 38.48, "10th_percentile": 38.48, "90th_percentile": 38.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 19.47, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19.47, "10th_percentile": 19.47, "90th_percentile": 19.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 47.99, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 47.99, "10th_percentile": 47.99, "90th_percentile": 47.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 42.67, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 42.67, "10th_percentile": 42.67, "90th_percentile": 42.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 61.95, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 61.95, "10th_percentile": 61.95, "90th_percentile": 61.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 24.81, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 24.81, "10th_percentile": 24.81, "90th_percentile": 24.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 15.0, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15.0, "10th_percentile": 15.0, "90th_percentile": 15.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 55.06, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 55.06, "10th_percentile": 55.06, "90th_percentile": 55.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 34.42, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 34.42, "10th_percentile": 34.42, "90th_percentile": 34.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 11.22, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 11.22, "10th_percentile": 11.22, "90th_percentile": 11.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 47.99, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 47.99, "10th_percentile": 47.99, "90th_percentile": 47.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 46.74, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 46.74, "10th_percentile": 46.74, "90th_percentile": 46.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "CATH ANGIO DIAG C1 TORC NB ADV", "code_information": [ { "code": "SUP-112047", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 35.26, "maximum": 216.32, "setting": "outpatient", "gross_charge": 216.32, "discounted_cash": 151.42, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 194.69, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 194.69, "10th_percentile": 194.69, "90th_percentile": 194.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 140.61, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 140.61, "10th_percentile": 140.61, "90th_percentile": 140.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 183.87, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 183.87, "10th_percentile": 183.87, "90th_percentile": 183.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 216.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 216.32, "10th_percentile": 216.32, "90th_percentile": 216.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 102.54, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 102.54, "10th_percentile": 102.54, "90th_percentile": 102.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 114.0, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 114.0, "10th_percentile": 114.0, "90th_percentile": 114.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 216.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 216.32, "10th_percentile": 216.32, "90th_percentile": 216.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 138.94, "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": 138.94, "10th_percentile": 138.94, "90th_percentile": 138.94, "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": "DCH PHCS", "standard_charge_dollar": 162.24, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 162.24, "10th_percentile": 162.24, "90th_percentile": 162.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 136.28, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 136.28, "10th_percentile": 136.28, "90th_percentile": 136.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 216.32, "10th_percentile": 216.32, "90th_percentile": 216.32, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 216.32, "10th_percentile": 216.32, "90th_percentile": 216.32, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 216.32, "10th_percentile": 216.32, "90th_percentile": 216.32, "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": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 62.39, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 62.39, "10th_percentile": 62.39, "90th_percentile": 62.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 60.57, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 60.57, "10th_percentile": 60.57, "90th_percentile": 60.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 77.96, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 77.96, "10th_percentile": 77.96, "90th_percentile": 77.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 120.92, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 120.92, "10th_percentile": 120.92, "90th_percentile": 120.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 61.18, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 61.18, "10th_percentile": 61.18, "90th_percentile": 61.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 150.82, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 150.82, "10th_percentile": 150.82, "90th_percentile": 150.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 134.12, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 134.12, "10th_percentile": 134.12, "90th_percentile": 134.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 134.12, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 134.12, "10th_percentile": 134.12, "90th_percentile": 134.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 194.69, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 194.69, "10th_percentile": 194.69, "90th_percentile": 194.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 108.16, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 108.16, "10th_percentile": 108.16, "90th_percentile": 108.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 162.24, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 162.24, "10th_percentile": 162.24, "90th_percentile": 162.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 77.96, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 77.96, "10th_percentile": 77.96, "90th_percentile": 77.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 47.16, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 47.16, "10th_percentile": 47.16, "90th_percentile": 47.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 106.0, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 106.0, "10th_percentile": 106.0, "90th_percentile": 106.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 173.06, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 173.06, "10th_percentile": 173.06, "90th_percentile": 173.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 108.16, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 108.16, "10th_percentile": 108.16, "90th_percentile": 108.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 35.26, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 35.26, "10th_percentile": 35.26, "90th_percentile": 35.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 173.06, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 173.06, "10th_percentile": 173.06, "90th_percentile": 173.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 150.82, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 150.82, "10th_percentile": 150.82, "90th_percentile": 150.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 149.26, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 149.26, "10th_percentile": 149.26, "90th_percentile": 149.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 146.88, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 146.88, "10th_percentile": 146.88, "90th_percentile": 146.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 216.32, "10th_percentile": 216.32, "90th_percentile": 216.32, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 216.32, "10th_percentile": 216.32, "90th_percentile": 216.32, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 216.32, "10th_percentile": 216.32, "90th_percentile": 216.32, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 216.32, "10th_percentile": 216.32, "90th_percentile": 216.32, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 216.32, "10th_percentile": 216.32, "90th_percentile": 216.32, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 216.32, "10th_percentile": 216.32, "90th_percentile": 216.32, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 216.32, "10th_percentile": 216.32, "90th_percentile": 216.32, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 216.32, "10th_percentile": 216.32, "90th_percentile": 216.32, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "CATH ANGIO DIAG JL4 INFINITI 5", "code_information": [ { "code": "SUP-316121", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 22.44, "maximum": 137.66, "setting": "outpatient", "gross_charge": 137.66, "discounted_cash": 96.36, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 85.35, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 85.35, "10th_percentile": 85.35, "90th_percentile": 85.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 85.35, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 85.35, "10th_percentile": 85.35, "90th_percentile": 85.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 39.7, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 39.7, "10th_percentile": 39.7, "90th_percentile": 39.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 95.98, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 95.98, "10th_percentile": 95.98, "90th_percentile": 95.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 38.93, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 38.93, "10th_percentile": 38.93, "90th_percentile": 38.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 76.95, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 76.95, "10th_percentile": 76.95, "90th_percentile": 76.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 49.61, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 38.54, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 38.54, "10th_percentile": 38.54, "90th_percentile": 38.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 123.89, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 123.89, "10th_percentile": 123.89, "90th_percentile": 123.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 123.89, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 123.89, "10th_percentile": 123.89, "90th_percentile": 123.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 68.83, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 89.48, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 89.48, "10th_percentile": 89.48, "90th_percentile": 89.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 103.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 103.25, "10th_percentile": 103.25, "90th_percentile": 103.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 117.01, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 117.01, "10th_percentile": 117.01, "90th_percentile": 117.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 93.47, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 93.47, "10th_percentile": 93.47, "90th_percentile": 93.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 137.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 110.13, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 110.13, "10th_percentile": 110.13, "90th_percentile": 110.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 65.25, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 65.25, "10th_percentile": 65.25, "90th_percentile": 65.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 72.55, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 72.55, "10th_percentile": 72.55, "90th_percentile": 72.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 137.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 88.42, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 88.42, "10th_percentile": 88.42, "90th_percentile": 88.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 103.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 103.25, "10th_percentile": 103.25, "90th_percentile": 103.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 30.01, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 30.01, "10th_percentile": 30.01, "90th_percentile": 30.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 110.13, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 110.13, "10th_percentile": 110.13, "90th_percentile": 110.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 67.45, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 67.45, "10th_percentile": 67.45, "90th_percentile": 67.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 68.83, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 95.98, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 95.98, "10th_percentile": 95.98, "90th_percentile": 95.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 94.99, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 94.99, "10th_percentile": 94.99, "90th_percentile": 94.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 22.44, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 22.44, "10th_percentile": 22.44, "90th_percentile": 22.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 49.61, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 86.73, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 86.73, "10th_percentile": 86.73, "90th_percentile": 86.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "CATH ANGIO DIAG JL4.5 EXPO 6FR", "code_information": [ { "code": "SUP-301641", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 11.22, "maximum": 68.83, "setting": "outpatient", "gross_charge": 68.83, "discounted_cash": 48.18, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 32.63, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 32.63, "10th_percentile": 32.63, "90th_percentile": 32.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 68.83, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 36.27, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 36.27, "10th_percentile": 36.27, "90th_percentile": 36.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 19.47, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19.47, "10th_percentile": 19.47, "90th_percentile": 19.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 19.27, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19.27, "10th_percentile": 19.27, "90th_percentile": 19.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 38.48, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 38.48, "10th_percentile": 38.48, "90th_percentile": 38.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 24.81, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 24.81, "10th_percentile": 24.81, "90th_percentile": 24.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 47.99, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 47.99, "10th_percentile": 47.99, "90th_percentile": 47.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 19.85, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19.85, "10th_percentile": 19.85, "90th_percentile": 19.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 61.95, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 61.95, "10th_percentile": 61.95, "90th_percentile": 61.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 61.95, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 61.95, "10th_percentile": 61.95, "90th_percentile": 61.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 68.83, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 51.62, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 51.62, "10th_percentile": 51.62, "90th_percentile": 51.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 46.74, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 46.74, "10th_percentile": 46.74, "90th_percentile": 46.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH THE ALLIANCE", "standard_charge_dollar": 44.21, "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": 44.21, "10th_percentile": 44.21, "90th_percentile": 44.21, "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": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 34.42, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 34.42, "10th_percentile": 34.42, "90th_percentile": 34.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 47.49, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 47.49, "10th_percentile": 47.49, "90th_percentile": 47.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 47.99, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 47.99, "10th_percentile": 47.99, "90th_percentile": 47.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH COMPSYCH", "standard_charge_dollar": 55.06, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 55.06, "10th_percentile": 55.06, "90th_percentile": 55.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 11.22, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 11.22, "10th_percentile": 11.22, "90th_percentile": 11.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 43.36, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 43.36, "10th_percentile": 43.36, "90th_percentile": 43.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 24.81, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 24.81, "10th_percentile": 24.81, "90th_percentile": 24.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 15.0, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15.0, "10th_percentile": 15.0, "90th_percentile": 15.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 33.73, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 33.73, "10th_percentile": 33.73, "90th_percentile": 33.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 55.06, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 55.06, "10th_percentile": 55.06, "90th_percentile": 55.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 58.51, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 58.51, "10th_percentile": 58.51, "90th_percentile": 58.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 34.42, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 34.42, "10th_percentile": 34.42, "90th_percentile": 34.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 51.62, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 51.62, "10th_percentile": 51.62, "90th_percentile": 51.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 44.74, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 44.74, "10th_percentile": 44.74, "90th_percentile": 44.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 42.67, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 42.67, "10th_percentile": 42.67, "90th_percentile": 42.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 42.67, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 42.67, "10th_percentile": 42.67, "90th_percentile": 42.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "CATH ANGIO DIAG JL6 SUP TORQ + 6FRX100CM", "code_information": [ { "code": "SUP-9023921", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 22.44, "maximum": 137.66, "setting": "outpatient", "gross_charge": 137.66, "discounted_cash": 96.36, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 39.7, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 39.7, "10th_percentile": 39.7, "90th_percentile": 39.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 38.54, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 38.54, "10th_percentile": 38.54, "90th_percentile": 38.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 49.61, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 76.95, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 76.95, "10th_percentile": 76.95, "90th_percentile": 76.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 38.93, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 38.93, "10th_percentile": 38.93, "90th_percentile": 38.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 95.98, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 95.98, "10th_percentile": 95.98, "90th_percentile": 95.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 85.35, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 85.35, "10th_percentile": 85.35, "90th_percentile": 85.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 123.89, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 123.89, "10th_percentile": 123.89, "90th_percentile": 123.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 68.83, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 89.48, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 89.48, "10th_percentile": 89.48, "90th_percentile": 89.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 103.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 103.25, "10th_percentile": 103.25, "90th_percentile": 103.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 117.01, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 117.01, "10th_percentile": 117.01, "90th_percentile": 117.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 65.25, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 65.25, "10th_percentile": 65.25, "90th_percentile": 65.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 137.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 72.55, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 72.55, "10th_percentile": 72.55, "90th_percentile": 72.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 86.73, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 86.73, "10th_percentile": 86.73, "90th_percentile": 86.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 30.01, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 30.01, "10th_percentile": 30.01, "90th_percentile": 30.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 67.45, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 67.45, "10th_percentile": 67.45, "90th_percentile": 67.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 110.13, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 110.13, "10th_percentile": 110.13, "90th_percentile": 110.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 68.83, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 110.13, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 110.13, "10th_percentile": 110.13, "90th_percentile": 110.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 88.42, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 88.42, "10th_percentile": 88.42, "90th_percentile": 88.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 103.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 103.25, "10th_percentile": 103.25, "90th_percentile": 103.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 94.99, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 94.99, "10th_percentile": 94.99, "90th_percentile": 94.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 137.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 123.89, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 123.89, "10th_percentile": 123.89, "90th_percentile": 123.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 93.47, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 93.47, "10th_percentile": 93.47, "90th_percentile": 93.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 95.98, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 95.98, "10th_percentile": 95.98, "90th_percentile": 95.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 22.44, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 22.44, "10th_percentile": 22.44, "90th_percentile": 22.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 49.61, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 85.35, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 85.35, "10th_percentile": 85.35, "90th_percentile": 85.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "CATH ANGIO DIAG JR4 INFINITI 5", "code_information": [ { "code": "SUP-316120", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 22.44, "maximum": 137.66, "setting": "outpatient", "gross_charge": 137.66, "discounted_cash": 96.36, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 85.35, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 85.35, "10th_percentile": 85.35, "90th_percentile": 85.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 85.35, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 85.35, "10th_percentile": 85.35, "90th_percentile": 85.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 39.7, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 39.7, "10th_percentile": 39.7, "90th_percentile": 39.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 95.98, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 95.98, "10th_percentile": 95.98, "90th_percentile": 95.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 38.93, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 38.93, "10th_percentile": 38.93, "90th_percentile": 38.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 76.95, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 76.95, "10th_percentile": 76.95, "90th_percentile": 76.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 49.61, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 38.54, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 38.54, "10th_percentile": 38.54, "90th_percentile": 38.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 123.89, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 123.89, "10th_percentile": 123.89, "90th_percentile": 123.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 123.89, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 123.89, "10th_percentile": 123.89, "90th_percentile": 123.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 68.83, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 89.48, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 89.48, "10th_percentile": 89.48, "90th_percentile": 89.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 103.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 103.25, "10th_percentile": 103.25, "90th_percentile": 103.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 117.01, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 117.01, "10th_percentile": 117.01, "90th_percentile": 117.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 93.47, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 93.47, "10th_percentile": 93.47, "90th_percentile": 93.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 137.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 110.13, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 110.13, "10th_percentile": 110.13, "90th_percentile": 110.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 88.42, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 88.42, "10th_percentile": 88.42, "90th_percentile": 88.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 103.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 103.25, "10th_percentile": 103.25, "90th_percentile": 103.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 30.01, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 30.01, "10th_percentile": 30.01, "90th_percentile": 30.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 110.13, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 110.13, "10th_percentile": 110.13, "90th_percentile": 110.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 67.45, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 67.45, "10th_percentile": 67.45, "90th_percentile": 67.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 68.83, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 95.98, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 95.98, "10th_percentile": 95.98, "90th_percentile": 95.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 94.99, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 94.99, "10th_percentile": 94.99, "90th_percentile": 94.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 22.44, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 22.44, "10th_percentile": 22.44, "90th_percentile": 22.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 49.61, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 86.73, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 86.73, "10th_percentile": 86.73, "90th_percentile": 86.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 137.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 72.55, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 72.55, "10th_percentile": 72.55, "90th_percentile": 72.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 65.25, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 65.25, "10th_percentile": 65.25, "90th_percentile": 65.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "CATH ANGIO DIAG JR4 SUP TORQ + 5.2FRX100CM", "code_information": [ { "code": "SUP-104937", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 12.02, "maximum": 73.74, "setting": "outpatient", "gross_charge": 73.74, "discounted_cash": 51.62, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 21.27, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 21.27, "10th_percentile": 21.27, "90th_percentile": 21.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 20.65, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.65, "10th_percentile": 20.65, "90th_percentile": 20.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 26.58, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 26.58, "10th_percentile": 26.58, "90th_percentile": 26.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 41.22, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 41.22, "10th_percentile": 41.22, "90th_percentile": 41.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 20.85, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.85, "10th_percentile": 20.85, "90th_percentile": 20.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 51.41, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 51.41, "10th_percentile": 51.41, "90th_percentile": 51.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 45.72, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 45.72, "10th_percentile": 45.72, "90th_percentile": 45.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 45.72, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 45.72, "10th_percentile": 45.72, "90th_percentile": 45.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 66.37, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 66.37, "10th_percentile": 66.37, "90th_percentile": 66.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 66.37, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 66.37, "10th_percentile": 66.37, "90th_percentile": 66.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 36.87, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 36.87, "10th_percentile": 36.87, "90th_percentile": 36.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 47.93, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 47.93, "10th_percentile": 47.93, "90th_percentile": 47.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 55.31, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 55.31, "10th_percentile": 55.31, "90th_percentile": 55.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 62.68, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 62.68, "10th_percentile": 62.68, "90th_percentile": 62.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 26.58, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 26.58, "10th_percentile": 26.58, "90th_percentile": 26.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 34.95, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 34.95, "10th_percentile": 34.95, "90th_percentile": 34.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 73.74, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 73.74, "10th_percentile": 73.74, "90th_percentile": 73.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 38.86, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 38.86, "10th_percentile": 38.86, "90th_percentile": 38.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 46.46, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 46.46, "10th_percentile": 46.46, "90th_percentile": 46.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 16.08, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.08, "10th_percentile": 16.08, "90th_percentile": 16.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 36.13, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 36.13, "10th_percentile": 36.13, "90th_percentile": 36.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 58.99, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 58.99, "10th_percentile": 58.99, "90th_percentile": 58.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 36.87, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 36.87, "10th_percentile": 36.87, "90th_percentile": 36.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 12.02, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 12.02, "10th_percentile": 12.02, "90th_percentile": 12.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 58.99, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 58.99, "10th_percentile": 58.99, "90th_percentile": 58.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 47.36, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 47.36, "10th_percentile": 47.36, "90th_percentile": 47.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 55.31, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 55.31, "10th_percentile": 55.31, "90th_percentile": 55.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 51.41, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 51.41, "10th_percentile": 51.41, "90th_percentile": 51.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 50.88, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 50.88, "10th_percentile": 50.88, "90th_percentile": 50.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 50.07, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 50.07, "10th_percentile": 50.07, "90th_percentile": 50.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 73.74, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 73.74, "10th_percentile": 73.74, "90th_percentile": 73.74, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 73.74, "10th_percentile": 73.74, "90th_percentile": 73.74, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 73.74, "10th_percentile": 73.74, "90th_percentile": 73.74, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 73.74, "10th_percentile": 73.74, "90th_percentile": 73.74, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 73.74, "10th_percentile": 73.74, "90th_percentile": 73.74, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 73.74, "10th_percentile": 73.74, "90th_percentile": 73.74, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 73.74, "10th_percentile": 73.74, "90th_percentile": 73.74, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 73.74, "10th_percentile": 73.74, "90th_percentile": 73.74, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 73.74, "10th_percentile": 73.74, "90th_percentile": 73.74, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 73.74, "10th_percentile": 73.74, "90th_percentile": 73.74, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 73.74, "10th_percentile": 73.74, "90th_percentile": 73.74, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 73.74, "10th_percentile": 73.74, "90th_percentile": 73.74, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "CATH ANGIO DIAG LCB EXPO 6FRX1", "code_information": [ { "code": "SUP-301635", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 11.22, "maximum": 68.83, "setting": "outpatient", "gross_charge": 68.83, "discounted_cash": 48.18, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 42.67, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 42.67, "10th_percentile": 42.67, "90th_percentile": 42.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 42.67, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 42.67, "10th_percentile": 42.67, "90th_percentile": 42.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 19.85, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19.85, "10th_percentile": 19.85, "90th_percentile": 19.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 47.99, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 47.99, "10th_percentile": 47.99, "90th_percentile": 47.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 19.47, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19.47, "10th_percentile": 19.47, "90th_percentile": 19.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 38.48, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 38.48, "10th_percentile": 38.48, "90th_percentile": 38.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 24.81, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 24.81, "10th_percentile": 24.81, "90th_percentile": 24.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 19.27, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19.27, "10th_percentile": 19.27, "90th_percentile": 19.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 61.95, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 61.95, "10th_percentile": 61.95, "90th_percentile": 61.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 61.95, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 61.95, "10th_percentile": 61.95, "90th_percentile": 61.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 34.42, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 34.42, "10th_percentile": 34.42, "90th_percentile": 34.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 44.74, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 44.74, "10th_percentile": 44.74, "90th_percentile": 44.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 51.62, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 51.62, "10th_percentile": 51.62, "90th_percentile": 51.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 58.51, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 58.51, "10th_percentile": 58.51, "90th_percentile": 58.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 46.74, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 46.74, "10th_percentile": 46.74, "90th_percentile": 46.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 68.83, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 55.06, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 55.06, "10th_percentile": 55.06, "90th_percentile": 55.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 32.63, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 32.63, "10th_percentile": 32.63, "90th_percentile": 32.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 36.27, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 36.27, "10th_percentile": 36.27, "90th_percentile": 36.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 68.83, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 44.21, "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": 44.21, "10th_percentile": 44.21, "90th_percentile": 44.21, "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": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 51.62, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 51.62, "10th_percentile": 51.62, "90th_percentile": 51.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 15.0, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15.0, "10th_percentile": 15.0, "90th_percentile": 15.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 55.06, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 55.06, "10th_percentile": 55.06, "90th_percentile": 55.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 33.73, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 33.73, "10th_percentile": 33.73, "90th_percentile": 33.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 34.42, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 34.42, "10th_percentile": 34.42, "90th_percentile": 34.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 47.99, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 47.99, "10th_percentile": 47.99, "90th_percentile": 47.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 47.49, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 47.49, "10th_percentile": 47.49, "90th_percentile": 47.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 11.22, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 11.22, "10th_percentile": 11.22, "90th_percentile": 11.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 24.81, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 24.81, "10th_percentile": 24.81, "90th_percentile": 24.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 43.36, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 43.36, "10th_percentile": 43.36, "90th_percentile": 43.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "CATH ANGIO DIAG LCB INFINITI 4FRX100CM", "code_information": [ { "code": "SUP-357602", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 11.54, "maximum": 70.79, "setting": "outpatient", "gross_charge": 70.79, "discounted_cash": 49.55, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 43.89, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 43.89, "10th_percentile": 43.89, "90th_percentile": 43.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 43.89, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 43.89, "10th_percentile": 43.89, "90th_percentile": 43.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 20.42, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.42, "10th_percentile": 20.42, "90th_percentile": 20.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 49.35, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 49.35, "10th_percentile": 49.35, "90th_percentile": 49.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 20.02, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.02, "10th_percentile": 20.02, "90th_percentile": 20.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 39.57, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 39.57, "10th_percentile": 39.57, "90th_percentile": 39.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 25.51, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 25.51, "10th_percentile": 25.51, "90th_percentile": 25.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 19.82, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19.82, "10th_percentile": 19.82, "90th_percentile": 19.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 63.71, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 63.71, "10th_percentile": 63.71, "90th_percentile": 63.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 63.71, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 63.71, "10th_percentile": 63.71, "90th_percentile": 63.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 35.4, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 35.4, "10th_percentile": 35.4, "90th_percentile": 35.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 46.01, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 46.01, "10th_percentile": 46.01, "90th_percentile": 46.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 53.09, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 53.09, "10th_percentile": 53.09, "90th_percentile": 53.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 60.17, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 60.17, "10th_percentile": 60.17, "90th_percentile": 60.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 48.07, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 48.07, "10th_percentile": 48.07, "90th_percentile": 48.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 70.79, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 70.79, "10th_percentile": 70.79, "90th_percentile": 70.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 56.63, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 56.63, "10th_percentile": 56.63, "90th_percentile": 56.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 33.55, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 33.55, "10th_percentile": 33.55, "90th_percentile": 33.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 37.31, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 37.31, "10th_percentile": 37.31, "90th_percentile": 37.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 70.79, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 70.79, "10th_percentile": 70.79, "90th_percentile": 70.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 45.47, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 45.47, "10th_percentile": 45.47, "90th_percentile": 45.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 53.09, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 53.09, "10th_percentile": 53.09, "90th_percentile": 53.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 15.43, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15.43, "10th_percentile": 15.43, "90th_percentile": 15.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 56.63, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 56.63, "10th_percentile": 56.63, "90th_percentile": 56.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 34.69, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 34.69, "10th_percentile": 34.69, "90th_percentile": 34.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 35.4, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 35.4, "10th_percentile": 35.4, "90th_percentile": 35.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 49.35, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 49.35, "10th_percentile": 49.35, "90th_percentile": 49.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 48.85, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 48.85, "10th_percentile": 48.85, "90th_percentile": 48.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 11.54, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 11.54, "10th_percentile": 11.54, "90th_percentile": 11.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 25.51, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 25.51, "10th_percentile": 25.51, "90th_percentile": 25.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 44.6, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 44.6, "10th_percentile": 44.6, "90th_percentile": 44.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 70.79, "10th_percentile": 70.79, "90th_percentile": 70.79, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 70.79, "10th_percentile": 70.79, "90th_percentile": 70.79, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 70.79, "10th_percentile": 70.79, "90th_percentile": 70.79, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 70.79, "10th_percentile": 70.79, "90th_percentile": 70.79, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 70.79, "10th_percentile": 70.79, "90th_percentile": 70.79, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 70.79, "10th_percentile": 70.79, "90th_percentile": 70.79, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 70.79, "10th_percentile": 70.79, "90th_percentile": 70.79, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 70.79, "10th_percentile": 70.79, "90th_percentile": 70.79, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 70.79, "10th_percentile": 70.79, "90th_percentile": 70.79, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 70.79, "10th_percentile": 70.79, "90th_percentile": 70.79, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 70.79, "10th_percentile": 70.79, "90th_percentile": 70.79, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "CATH ANGIO DIAG PIG INFIN 5FRX", "code_information": [ { "code": "SUP-151383", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 22.44, "maximum": 137.66, "setting": "outpatient", "gross_charge": 137.66, "discounted_cash": 96.36, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 38.93, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 38.93, "10th_percentile": 38.93, "90th_percentile": 38.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 38.54, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 38.54, "10th_percentile": 38.54, "90th_percentile": 38.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 76.95, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 76.95, "10th_percentile": 76.95, "90th_percentile": 76.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 49.61, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 95.98, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 95.98, "10th_percentile": 95.98, "90th_percentile": 95.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 39.7, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 39.7, "10th_percentile": 39.7, "90th_percentile": 39.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 123.89, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 123.89, "10th_percentile": 123.89, "90th_percentile": 123.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 123.89, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 123.89, "10th_percentile": 123.89, "90th_percentile": 123.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 137.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 103.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 103.25, "10th_percentile": 103.25, "90th_percentile": 103.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 93.47, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 93.47, "10th_percentile": 93.47, "90th_percentile": 93.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH THE ALLIANCE", "standard_charge_dollar": 88.42, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 88.42, "10th_percentile": 88.42, "90th_percentile": 88.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 68.83, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 94.99, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 94.99, "10th_percentile": 94.99, "90th_percentile": 94.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 95.98, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 95.98, "10th_percentile": 95.98, "90th_percentile": 95.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH COMPSYCH", "standard_charge_dollar": 110.13, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 110.13, "10th_percentile": 110.13, "90th_percentile": 110.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 22.44, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 22.44, "10th_percentile": 22.44, "90th_percentile": 22.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 86.73, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 86.73, "10th_percentile": 86.73, "90th_percentile": 86.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 49.61, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 30.01, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 30.01, "10th_percentile": 30.01, "90th_percentile": 30.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 67.45, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 67.45, "10th_percentile": 67.45, "90th_percentile": 67.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 110.13, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 110.13, "10th_percentile": 110.13, "90th_percentile": 110.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 137.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 72.55, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 72.55, "10th_percentile": 72.55, "90th_percentile": 72.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 65.25, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 65.25, "10th_percentile": 65.25, "90th_percentile": 65.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 117.01, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 117.01, "10th_percentile": 117.01, "90th_percentile": 117.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 68.83, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 103.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 103.25, "10th_percentile": 103.25, "90th_percentile": 103.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 89.48, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 89.48, "10th_percentile": 89.48, "90th_percentile": 89.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 85.35, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 85.35, "10th_percentile": 85.35, "90th_percentile": 85.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 85.35, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 85.35, "10th_percentile": 85.35, "90th_percentile": 85.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.66, "10th_percentile": 137.66, "90th_percentile": 137.66, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "CATH ANGIO DIAG RCB EXPO SNGL", "code_information": [ { "code": "SUP-340799", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 11.22, "maximum": 68.83, "setting": "outpatient", "gross_charge": 68.83, "discounted_cash": 48.18, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 19.85, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19.85, "10th_percentile": 19.85, "90th_percentile": 19.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 19.27, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19.27, "10th_percentile": 19.27, "90th_percentile": 19.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 24.81, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 24.81, "10th_percentile": 24.81, "90th_percentile": 24.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 38.48, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 38.48, "10th_percentile": 38.48, "90th_percentile": 38.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 19.47, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19.47, "10th_percentile": 19.47, "90th_percentile": 19.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 47.99, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 47.99, "10th_percentile": 47.99, "90th_percentile": 47.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 42.67, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 42.67, "10th_percentile": 42.67, "90th_percentile": 42.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 42.67, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 42.67, "10th_percentile": 42.67, "90th_percentile": 42.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 61.95, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 61.95, "10th_percentile": 61.95, "90th_percentile": 61.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 61.95, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 61.95, "10th_percentile": 61.95, "90th_percentile": 61.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 34.42, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 34.42, "10th_percentile": 34.42, "90th_percentile": 34.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 44.74, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 44.74, "10th_percentile": 44.74, "90th_percentile": 44.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 51.62, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 51.62, "10th_percentile": 51.62, "90th_percentile": 51.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 58.51, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 58.51, "10th_percentile": 58.51, "90th_percentile": 58.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 24.81, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 24.81, "10th_percentile": 24.81, "90th_percentile": 24.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 43.36, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 43.36, "10th_percentile": 43.36, "90th_percentile": 43.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 15.0, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15.0, "10th_percentile": 15.0, "90th_percentile": 15.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 33.73, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 33.73, "10th_percentile": 33.73, "90th_percentile": 33.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 55.06, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 55.06, "10th_percentile": 55.06, "90th_percentile": 55.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 34.42, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 34.42, "10th_percentile": 34.42, "90th_percentile": 34.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 11.22, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 11.22, "10th_percentile": 11.22, "90th_percentile": 11.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 55.06, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 55.06, "10th_percentile": 55.06, "90th_percentile": 55.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 51.62, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 51.62, "10th_percentile": 51.62, "90th_percentile": 51.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 47.99, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 47.99, "10th_percentile": 47.99, "90th_percentile": 47.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 47.49, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 47.49, "10th_percentile": 47.49, "90th_percentile": 47.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 46.74, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 46.74, "10th_percentile": 46.74, "90th_percentile": 46.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 68.83, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 44.21, "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": 44.21, "10th_percentile": 44.21, "90th_percentile": 44.21, "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": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 68.83, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 68.83, "10th_percentile": 68.83, "90th_percentile": 68.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 36.27, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 36.27, "10th_percentile": 36.27, "90th_percentile": 36.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 32.63, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 32.63, "10th_percentile": 32.63, "90th_percentile": 32.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "CATH ANGIO DIAG RF HF PIG 5FR", "code_information": [ { "code": "SUP-339790", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 20.83, "maximum": 127.82, "setting": "outpatient", "gross_charge": 127.82, "discounted_cash": 89.47, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 36.86, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 36.86, "10th_percentile": 36.86, "90th_percentile": 36.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 35.79, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 35.79, "10th_percentile": 35.79, "90th_percentile": 35.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 46.07, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 46.07, "10th_percentile": 46.07, "90th_percentile": 46.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 71.45, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 71.45, "10th_percentile": 71.45, "90th_percentile": 71.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 36.15, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 36.15, "10th_percentile": 36.15, "90th_percentile": 36.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 89.12, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 89.12, "10th_percentile": 89.12, "90th_percentile": 89.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 79.25, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 79.25, "10th_percentile": 79.25, "90th_percentile": 79.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 79.25, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 79.25, "10th_percentile": 79.25, "90th_percentile": 79.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 115.04, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 115.04, "10th_percentile": 115.04, "90th_percentile": 115.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 115.04, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 115.04, "10th_percentile": 115.04, "90th_percentile": 115.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 63.91, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 63.91, "10th_percentile": 63.91, "90th_percentile": 63.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 83.08, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 83.08, "10th_percentile": 83.08, "90th_percentile": 83.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 95.87, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 95.87, "10th_percentile": 95.87, "90th_percentile": 95.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 108.65, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 108.65, "10th_percentile": 108.65, "90th_percentile": 108.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 46.07, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 46.07, "10th_percentile": 46.07, "90th_percentile": 46.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 60.59, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 60.59, "10th_percentile": 60.59, "90th_percentile": 60.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 127.82, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 127.82, "10th_percentile": 127.82, "90th_percentile": 127.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 67.36, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 67.36, "10th_percentile": 67.36, "90th_percentile": 67.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 80.53, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 80.53, "10th_percentile": 80.53, "90th_percentile": 80.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 27.86, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 27.86, "10th_percentile": 27.86, "90th_percentile": 27.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 62.63, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 62.63, "10th_percentile": 62.63, "90th_percentile": 62.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 102.26, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 102.26, "10th_percentile": 102.26, "90th_percentile": 102.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 63.91, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 63.91, "10th_percentile": 63.91, "90th_percentile": 63.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 20.83, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 20.83, "10th_percentile": 20.83, "90th_percentile": 20.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 102.26, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 102.26, "10th_percentile": 102.26, "90th_percentile": 102.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 82.1, "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": 82.1, "10th_percentile": 82.1, "90th_percentile": 82.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 95.87, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 95.87, "10th_percentile": 95.87, "90th_percentile": 95.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 89.12, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 89.12, "10th_percentile": 89.12, "90th_percentile": 89.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 88.2, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 88.2, "10th_percentile": 88.2, "90th_percentile": 88.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 86.79, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 86.79, "10th_percentile": 86.79, "90th_percentile": 86.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 127.82, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 127.82, "10th_percentile": 127.82, "90th_percentile": 127.82, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 127.82, "10th_percentile": 127.82, "90th_percentile": 127.82, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 127.82, "10th_percentile": 127.82, "90th_percentile": 127.82, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 127.82, "10th_percentile": 127.82, "90th_percentile": 127.82, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 127.82, "10th_percentile": 127.82, "90th_percentile": 127.82, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 127.82, "10th_percentile": 127.82, "90th_percentile": 127.82, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 127.82, "10th_percentile": 127.82, "90th_percentile": 127.82, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 127.82, "10th_percentile": 127.82, "90th_percentile": 127.82, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 127.82, "10th_percentile": 127.82, "90th_percentile": 127.82, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 127.82, "10th_percentile": 127.82, "90th_percentile": 127.82, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 127.82, "10th_percentile": 127.82, "90th_percentile": 127.82, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 127.82, "10th_percentile": 127.82, "90th_percentile": 127.82, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "CATH ANGIO DIAG SH TEMPO 4FRX6", "code_information": [ { "code": "SUP-303996", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 23.96, "maximum": 147.0, "setting": "outpatient", "gross_charge": 147.0, "discounted_cash": 102.9, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 91.14, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 91.14, "10th_percentile": 91.14, "90th_percentile": 91.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 91.14, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 91.14, "10th_percentile": 91.14, "90th_percentile": 91.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 42.39, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 42.39, "10th_percentile": 42.39, "90th_percentile": 42.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 102.49, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 102.49, "10th_percentile": 102.49, "90th_percentile": 102.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 41.57, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 41.57, "10th_percentile": 41.57, "90th_percentile": 41.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 82.17, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 82.17, "10th_percentile": 82.17, "90th_percentile": 82.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 52.98, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 52.98, "10th_percentile": 52.98, "90th_percentile": 52.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 41.16, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 41.16, "10th_percentile": 41.16, "90th_percentile": 41.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 132.3, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 132.3, "10th_percentile": 132.3, "90th_percentile": 132.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 132.3, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 132.3, "10th_percentile": 132.3, "90th_percentile": 132.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 73.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 73.5, "10th_percentile": 73.5, "90th_percentile": 73.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 95.55, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 95.55, "10th_percentile": 95.55, "90th_percentile": 95.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 110.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 110.25, "10th_percentile": 110.25, "90th_percentile": 110.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 124.95, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 124.95, "10th_percentile": 124.95, "90th_percentile": 124.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 99.81, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 99.81, "10th_percentile": 99.81, "90th_percentile": 99.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 147.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 147.0, "10th_percentile": 147.0, "90th_percentile": 147.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 117.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 117.6, "10th_percentile": 117.6, "90th_percentile": 117.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 69.68, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 69.68, "10th_percentile": 69.68, "90th_percentile": 69.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 77.47, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 77.47, "10th_percentile": 77.47, "90th_percentile": 77.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 147.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 147.0, "10th_percentile": 147.0, "90th_percentile": 147.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 94.42, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 94.42, "10th_percentile": 94.42, "90th_percentile": 94.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 110.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 110.25, "10th_percentile": 110.25, "90th_percentile": 110.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 32.05, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 32.05, "10th_percentile": 32.05, "90th_percentile": 32.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 117.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 117.6, "10th_percentile": 117.6, "90th_percentile": 117.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 72.03, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 72.03, "10th_percentile": 72.03, "90th_percentile": 72.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 73.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 73.5, "10th_percentile": 73.5, "90th_percentile": 73.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 102.49, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 102.49, "10th_percentile": 102.49, "90th_percentile": 102.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 101.43, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 101.43, "10th_percentile": 101.43, "90th_percentile": 101.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 23.96, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 23.96, "10th_percentile": 23.96, "90th_percentile": 23.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 52.98, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 52.98, "10th_percentile": 52.98, "90th_percentile": 52.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 92.61, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 92.61, "10th_percentile": 92.61, "90th_percentile": 92.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 147.0, "10th_percentile": 147.0, "90th_percentile": 147.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 147.0, "10th_percentile": 147.0, "90th_percentile": 147.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 147.0, "10th_percentile": 147.0, "90th_percentile": 147.0, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 147.0, "10th_percentile": 147.0, "90th_percentile": 147.0, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 147.0, "10th_percentile": 147.0, "90th_percentile": 147.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 147.0, "10th_percentile": 147.0, "90th_percentile": 147.0, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 147.0, "10th_percentile": 147.0, "90th_percentile": 147.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 147.0, "10th_percentile": 147.0, "90th_percentile": 147.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 147.0, "10th_percentile": 147.0, "90th_percentile": 147.0, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 147.0, "10th_percentile": 147.0, "90th_percentile": 147.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 147.0, "10th_percentile": 147.0, "90th_percentile": 147.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "CATH ANGIO DIAG SIM2 NON-BEAC", "code_information": [ { "code": "SUP-314878", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 20.83, "maximum": 127.82, "setting": "outpatient", "gross_charge": 127.82, "discounted_cash": 89.47, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 79.25, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 79.25, "10th_percentile": 79.25, "90th_percentile": 79.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 79.25, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 79.25, "10th_percentile": 79.25, "90th_percentile": 79.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 36.86, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 36.86, "10th_percentile": 36.86, "90th_percentile": 36.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 89.12, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 89.12, "10th_percentile": 89.12, "90th_percentile": 89.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 36.15, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 36.15, "10th_percentile": 36.15, "90th_percentile": 36.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 71.45, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 71.45, "10th_percentile": 71.45, "90th_percentile": 71.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 46.07, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 46.07, "10th_percentile": 46.07, "90th_percentile": 46.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 35.79, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 35.79, "10th_percentile": 35.79, "90th_percentile": 35.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 115.04, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 115.04, "10th_percentile": 115.04, "90th_percentile": 115.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 115.04, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 115.04, "10th_percentile": 115.04, "90th_percentile": 115.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 63.91, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 63.91, "10th_percentile": 63.91, "90th_percentile": 63.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 83.08, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 83.08, "10th_percentile": 83.08, "90th_percentile": 83.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 95.87, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 95.87, "10th_percentile": 95.87, "90th_percentile": 95.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 108.65, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 108.65, "10th_percentile": 108.65, "90th_percentile": 108.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 86.79, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 86.79, "10th_percentile": 86.79, "90th_percentile": 86.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 127.82, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 127.82, "10th_percentile": 127.82, "90th_percentile": 127.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 102.26, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 102.26, "10th_percentile": 102.26, "90th_percentile": 102.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 60.59, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 60.59, "10th_percentile": 60.59, "90th_percentile": 60.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 67.36, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 67.36, "10th_percentile": 67.36, "90th_percentile": 67.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 127.82, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 127.82, "10th_percentile": 127.82, "90th_percentile": 127.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 82.1, "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": 82.1, "10th_percentile": 82.1, "90th_percentile": 82.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 95.87, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 95.87, "10th_percentile": 95.87, "90th_percentile": 95.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 27.86, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 27.86, "10th_percentile": 27.86, "90th_percentile": 27.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 102.26, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 102.26, "10th_percentile": 102.26, "90th_percentile": 102.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 62.63, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 62.63, "10th_percentile": 62.63, "90th_percentile": 62.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 63.91, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 63.91, "10th_percentile": 63.91, "90th_percentile": 63.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 89.12, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 89.12, "10th_percentile": 89.12, "90th_percentile": 89.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 88.2, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 88.2, "10th_percentile": 88.2, "90th_percentile": 88.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 20.83, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 20.83, "10th_percentile": 20.83, "90th_percentile": 20.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 46.07, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 46.07, "10th_percentile": 46.07, "90th_percentile": 46.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 80.53, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 80.53, "10th_percentile": 80.53, "90th_percentile": 80.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 127.82, "10th_percentile": 127.82, "90th_percentile": 127.82, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 127.82, "10th_percentile": 127.82, "90th_percentile": 127.82, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 127.82, "10th_percentile": 127.82, "90th_percentile": 127.82, "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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 127.82, "10th_percentile": 127.82, "90th_percentile": 127.82, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 127.82, "10th_percentile": 127.82, "90th_percentile": 127.82, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 127.82, "10th_percentile": 127.82, "90th_percentile": 127.82, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 127.82, "10th_percentile": 127.82, "90th_percentile": 127.82, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 127.82, "10th_percentile": 127.82, "90th_percentile": 127.82, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 127.82, "10th_percentile": 127.82, "90th_percentile": 127.82, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 127.82, "10th_percentile": 127.82, "90th_percentile": 127.82, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 127.82, "10th_percentile": 127.82, "90th_percentile": 127.82, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "CATH ANGIO DIAG SZG MOD HK SH 5FRX100CM", "code_information": [ { "code": "SUP-313523", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 152.26, "maximum": 934.09, "setting": "outpatient", "gross_charge": 934.09, "discounted_cash": 653.86, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 269.39, "standard_charge_percentage": 28.84, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 269.39, "10th_percentile": 269.39, "90th_percentile": 269.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.84% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 261.55, "standard_charge_percentage": 28.0, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 261.55, "10th_percentile": 261.55, "90th_percentile": 261.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 336.65, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 336.65, "10th_percentile": 336.65, "90th_percentile": 336.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 522.16, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 522.16, "10th_percentile": 522.16, "90th_percentile": 522.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 264.16, "standard_charge_percentage": 28.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 264.16, "10th_percentile": 264.16, "90th_percentile": 264.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 651.25, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 651.25, "10th_percentile": 651.25, "90th_percentile": 651.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 579.14, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 579.14, "10th_percentile": 579.14, "90th_percentile": 579.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 579.14, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 579.14, "10th_percentile": 579.14, "90th_percentile": 579.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MULTIPLAN", "standard_charge_dollar": 840.68, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 840.68, "10th_percentile": 840.68, "90th_percentile": 840.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 840.68, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 840.68, "10th_percentile": 840.68, "90th_percentile": 840.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 467.05, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 467.05, "10th_percentile": 467.05, "90th_percentile": 467.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 607.16, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 607.16, "10th_percentile": 607.16, "90th_percentile": 607.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 700.57, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 700.57, "10th_percentile": 700.57, "90th_percentile": 700.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 793.98, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 793.98, "10th_percentile": 793.98, "90th_percentile": 793.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 336.65, "standard_charge_percentage": 36.04, "standard_charge_algorithm": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 336.65, "10th_percentile": 336.65, "90th_percentile": 336.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 36.04% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 442.76, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 442.76, "10th_percentile": 442.76, "90th_percentile": 442.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 934.09, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 934.09, "10th_percentile": 934.09, "90th_percentile": 934.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 492.27, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 492.27, "10th_percentile": 492.27, "90th_percentile": 492.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 588.48, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 588.48, "10th_percentile": 588.48, "90th_percentile": 588.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 203.63, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 203.63, "10th_percentile": 203.63, "90th_percentile": 203.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 457.7, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 457.7, "10th_percentile": 457.7, "90th_percentile": 457.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 747.27, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 747.27, "10th_percentile": 747.27, "90th_percentile": 747.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 467.05, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 467.05, "10th_percentile": 467.05, "90th_percentile": 467.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 152.26, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 152.26, "10th_percentile": 152.26, "90th_percentile": 152.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 747.27, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 747.27, "10th_percentile": 747.27, "90th_percentile": 747.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 599.97, "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": 599.97, "10th_percentile": 599.97, "90th_percentile": 599.97, "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": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 700.57, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 700.57, "10th_percentile": 700.57, "90th_percentile": 700.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 651.25, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 651.25, "10th_percentile": 651.25, "90th_percentile": 651.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 644.52, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 644.52, "10th_percentile": 644.52, "90th_percentile": 644.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 634.25, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 634.25, "10th_percentile": 634.25, "90th_percentile": 634.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 934.09, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 934.09, "10th_percentile": 934.09, "90th_percentile": 934.09, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 934.09, "10th_percentile": 934.09, "90th_percentile": 934.09, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 934.09, "10th_percentile": 934.09, "90th_percentile": 934.09, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 934.09, "10th_percentile": 934.09, "90th_percentile": 934.09, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 934.09, "10th_percentile": 934.09, "90th_percentile": 934.09, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 934.09, "10th_percentile": 934.09, "90th_percentile": 934.09, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 934.09, "10th_percentile": 934.09, "90th_percentile": 934.09, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 934.09, "10th_percentile": 934.09, "90th_percentile": 934.09, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 934.09, "10th_percentile": 934.09, "90th_percentile": 934.09, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 934.09, "10th_percentile": 934.09, "90th_percentile": 934.09, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 934.09, "10th_percentile": 934.09, "90th_percentile": 934.09, "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": "DCH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 934.09, "10th_percentile": 934.09, "90th_percentile": 934.09, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "CATH ANGIO GUID ADV CRNRY SINU", "code_information": [ { "code": "SUP-317018", "type": "CDM" }, { "code": "C1892", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 571.37, "maximum": 3834.68, "setting": "outpatient", "gross_charge": 3834.68, "discounted_cash": 2684.28, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 2377.5, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2377.5, "10th_percentile": 2377.5, "90th_percentile": 2377.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 2603.75, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2603.75, "10th_percentile": 2603.75, "90th_percentile": 2603.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 625.05, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 625.05, "10th_percentile": 625.05, "90th_percentile": 625.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 2673.54, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2673.54, "10th_percentile": 2673.54, "90th_percentile": 2673.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 893.48, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 893.48, "10th_percentile": 893.48, "90th_percentile": 893.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 3451.21, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 3451.21, "10th_percentile": 3451.21, "90th_percentile": 3451.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 571.37, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 571.37, "10th_percentile": 571.37, "90th_percentile": 571.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 690.24, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 690.24, "10th_percentile": 690.24, "90th_percentile": 690.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 571.37, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 571.37, "10th_percentile": 571.37, "90th_percentile": 571.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 2673.54, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2673.54, "10th_percentile": 2673.54, "90th_percentile": 2673.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2143.59, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2143.59, "10th_percentile": 2143.59, "90th_percentile": 2143.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 893.48, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 893.48, "10th_percentile": 893.48, "90th_percentile": 893.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 1917.34, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1917.34, "10th_percentile": 1917.34, "90th_percentile": 1917.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 835.96, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 835.96, "10th_percentile": 835.96, "90th_percentile": 835.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 3067.74, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 3067.74, "10th_percentile": 3067.74, "90th_percentile": 3067.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 1878.99, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1878.99, "10th_percentile": 1878.99, "90th_percentile": 1878.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 3067.74, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 3067.74, "10th_percentile": 3067.74, "90th_percentile": 3067.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH AETNA", "standard_charge_dollar": 2377.5, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2377.5, "10th_percentile": 2377.5, "90th_percentile": 2377.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH FIRST HEALTH", "standard_charge_dollar": 2645.93, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 2645.93, "10th_percentile": 2645.93, "90th_percentile": 2645.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 2876.01, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 2876.01, "10th_percentile": 2876.01, "90th_percentile": 2876.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 1917.34, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 1917.34, "10th_percentile": 1917.34, "90th_percentile": 1917.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 2492.54, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 2492.54, "10th_percentile": 2492.54, "90th_percentile": 2492.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $3,834.68 @ 12.5% = $479.34 due to $0.00 Claim Price", "median_amount": 479.34, "10th_percentile": 479.34, "90th_percentile": 479.34, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $3,834.68 @ 12.5% = $479.34 due to $0.00 Claim Price" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $3,834.68 @ 6.8% = $260.76 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": 260.76, "10th_percentile": 260.76, "90th_percentile": 260.76, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $3,834.68 @ 6.8% = $260.76 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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $3,834.68 @ 6.8% = $260.76 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": 260.76, "10th_percentile": 260.76, "90th_percentile": 260.76, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $3,834.68 @ 6.8% = $260.76 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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $3,834.68 @ 6.8% = $260.76 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": 260.76, "10th_percentile": 260.76, "90th_percentile": 260.76, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $3,834.68 @ 6.8% = $260.76 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 BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3834.68, "10th_percentile": 3834.68, "90th_percentile": 3834.68, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3834.68, "10th_percentile": 3834.68, "90th_percentile": 3834.68, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3834.68, "10th_percentile": 3834.68, "90th_percentile": 3834.68, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3834.68, "10th_percentile": 3834.68, "90th_percentile": 3834.68, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3834.68, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3834.68, "10th_percentile": 3834.68, "90th_percentile": 3834.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 3259.48, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 3259.48, "10th_percentile": 3259.48, "90th_percentile": 3259.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 2415.85, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 2415.85, "10th_percentile": 2415.85, "90th_percentile": 2415.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 3451.21, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 3451.21, "10th_percentile": 3451.21, "90th_percentile": 3451.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 2876.01, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 2876.01, "10th_percentile": 2876.01, "90th_percentile": 2876.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 2463.01, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 2463.01, "10th_percentile": 2463.01, "90th_percentile": 2463.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 1817.64, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1817.64, "10th_percentile": 1817.64, "90th_percentile": 1817.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 2020.88, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2020.88, "10th_percentile": 2020.88, "90th_percentile": 2020.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 3834.68, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 3834.68, "10th_percentile": 3834.68, "90th_percentile": 3834.68, "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": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 3834.68, "10th_percentile": 3834.68, "90th_percentile": 3834.68, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3834.68, "10th_percentile": 3834.68, "90th_percentile": 3834.68, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3834.68, "10th_percentile": 3834.68, "90th_percentile": 3834.68, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "CATH ANGIO GUID C1 GLDECATH 5F", "code_information": [ { "code": "SUP-9004153", "type": "CDM" }, { "code": "C1887", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 77.91, "maximum": 522.89, "setting": "outpatient", "gross_charge": 522.89, "discounted_cash": 366.02, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 355.04, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 355.04, "10th_percentile": 355.04, "90th_percentile": 355.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 85.23, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 85.23, "10th_percentile": 85.23, "90th_percentile": 85.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 77.91, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 77.91, "10th_percentile": 77.91, "90th_percentile": 77.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 364.56, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 364.56, "10th_percentile": 364.56, "90th_percentile": 364.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 470.6, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 470.6, "10th_percentile": 470.6, "90th_percentile": 470.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 121.83, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 121.83, "10th_percentile": 121.83, "90th_percentile": 121.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 324.19, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 324.19, "10th_percentile": 324.19, "90th_percentile": 324.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 522.89, "10th_percentile": 522.89, "90th_percentile": 522.89, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 522.89, "10th_percentile": 522.89, "90th_percentile": 522.89, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 522.89, "10th_percentile": 522.89, "90th_percentile": 522.89, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 522.89, "10th_percentile": 522.89, "90th_percentile": 522.89, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 522.89, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 522.89, "10th_percentile": 522.89, "90th_percentile": 522.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 261.45, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 261.45, "10th_percentile": 261.45, "90th_percentile": 261.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 113.99, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 113.99, "10th_percentile": 113.99, "90th_percentile": 113.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 418.31, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 418.31, "10th_percentile": 418.31, "90th_percentile": 418.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 256.22, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 309.72, "10th_percentile": 309.72, "90th_percentile": 309.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 418.31, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 418.31, "10th_percentile": 418.31, "90th_percentile": 418.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 360.79, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 360.79, "10th_percentile": 360.79, "90th_percentile": 360.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 392.17, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 392.17, "10th_percentile": 392.17, "90th_percentile": 392.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 261.45, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 261.45, "10th_percentile": 261.45, "90th_percentile": 261.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 339.88, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 339.88, "10th_percentile": 339.88, "90th_percentile": 339.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 444.46, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 444.46, "10th_percentile": 444.46, "90th_percentile": 444.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 329.42, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 329.42, "10th_percentile": 329.42, "90th_percentile": 329.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 470.6, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 470.6, "10th_percentile": 470.6, "90th_percentile": 470.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 392.17, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 392.17, "10th_percentile": 392.17, "90th_percentile": 392.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 335.85, "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": 335.85, "10th_percentile": 335.85, "90th_percentile": 335.85, "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": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 247.85, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 247.85, "10th_percentile": 247.85, "90th_percentile": 247.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 275.56, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 275.56, "10th_percentile": 275.56, "90th_percentile": 275.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 522.89, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 522.89, "10th_percentile": 522.89, "90th_percentile": 522.89, "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": "DCH BCBS PPO", "standard_charge_dollar": 121.83, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 121.83, "10th_percentile": 121.83, "90th_percentile": 121.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 94.12, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 94.12, "10th_percentile": 94.12, "90th_percentile": 94.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 292.3, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 292.3, "10th_percentile": 292.3, "90th_percentile": 292.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 77.91, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 77.91, "10th_percentile": 77.91, "90th_percentile": 77.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 364.56, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 364.56, "10th_percentile": 364.56, "90th_percentile": 364.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 324.19, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 324.19, "10th_percentile": 324.19, "90th_percentile": 324.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $522.89 @ 12.5% = $65.36 due to $0.00 Claim Price", "median_amount": 65.36, "10th_percentile": 65.36, "90th_percentile": 65.36, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $522.89 @ 12.5% = $65.36 due to $0.00 Claim Price" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $522.89 @ 6.8% = $35.56 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": 35.56, "10th_percentile": 35.56, "90th_percentile": 35.56, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $522.89 @ 6.8% = $35.56 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": "COUNTYCARE IL COOK CO [1607]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $522.89 @ 6.8% = $35.56 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": 35.56, "10th_percentile": 35.56, "90th_percentile": 35.56, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $522.89 @ 6.8% = $35.56 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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $522.89 @ 6.8% = $35.56 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": 35.56, "10th_percentile": 35.56, "90th_percentile": 35.56, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $522.89 @ 6.8% = $35.56 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": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 522.89, "10th_percentile": 522.89, "90th_percentile": 522.89, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 522.89, "10th_percentile": 522.89, "90th_percentile": 522.89, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 522.89, "10th_percentile": 522.89, "90th_percentile": 522.89, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "CATH ANGIO GUID IL4 HEARTRAIL", "code_information": [ { "code": "SUP-147954", "type": "CDM" }, { "code": "C1887", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 139.18, "maximum": 934.09, "setting": "outpatient", "gross_charge": 934.09, "discounted_cash": 653.86, "payers_information": [ { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 588.48, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 588.48, "10th_percentile": 588.48, "90th_percentile": 588.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "DCH THE ALLIANCE", "standard_charge_dollar": 599.97, "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": 599.97, "10th_percentile": 599.97, "90th_percentile": 599.97, "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": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 934.09, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 934.09, "10th_percentile": 934.09, "90th_percentile": 934.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 934.09, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 934.09, "10th_percentile": 934.09, "90th_percentile": 934.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH PHCS", "standard_charge_dollar": 700.57, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "OP; 75% Billed", "median_amount": 700.57, "10th_percentile": 700.57, "90th_percentile": 700.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 442.76, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 442.76, "10th_percentile": 442.76, "90th_percentile": 442.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC HMO/PPO", "standard_charge_dollar": 492.27, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 492.27, "10th_percentile": 492.27, "90th_percentile": 492.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "DCH FIRST HEALTH", "standard_charge_dollar": 644.52, "standard_charge_percentage": 69.0, "standard_charge_algorithm": "All Outpatient Services; 69% Billed", "median_amount": 644.52, "10th_percentile": 644.52, "90th_percentile": 644.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 69% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PPO", "standard_charge_dollar": 793.98, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All procedures - 85% percent of billed; 85% Billed", "median_amount": 793.98, "10th_percentile": 793.98, "90th_percentile": 793.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 85% percent of billed; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN PLAT", "standard_charge_dollar": 607.16, "standard_charge_percentage": 65.0, "standard_charge_algorithm": "All procedures - 65% percent of billed; 65% Billed", "median_amount": 607.16, "10th_percentile": 607.16, "90th_percentile": 607.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All procedures - 65% percent of billed; 65% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN EPO", "standard_charge_dollar": 700.57, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "ALL SERVICES; 75% Billed", "median_amount": 700.57, "10th_percentile": 700.57, "90th_percentile": 700.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "DCH HFN NMH TIER ONE", "standard_charge_dollar": 467.05, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SRVS; 50% Billed", "median_amount": 467.05, "10th_percentile": 467.05, "90th_percentile": 467.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 50% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH MULTIPLAN", "standard_charge_dollar": 840.68, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 840.68, "10th_percentile": 840.68, "90th_percentile": 840.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "DCH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $934.09 @ 12.5% = $116.76 due to $0.00 Claim Price", "median_amount": 116.76, "10th_percentile": 116.76, "90th_percentile": 116.76, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR DCH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $934.09 @ 12.5% = $116.76 due to $0.00 Claim Price" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $934.09 @ 6.8% = $63.52 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": 63.52, "10th_percentile": 63.52, "90th_percentile": 63.52, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $934.09 @ 6.8% = $63.52 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": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "DCH UNITED BEHAVIORAL HEALTH", "standard_charge_algorithm": "No contract line matched", "median_amount": 934.09, "10th_percentile": 934.09, "90th_percentile": 934.09, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "DCH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 934.09, "10th_percentile": 934.09, "90th_percentile": 934.09, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 934.09, "10th_percentile": 934.09, "90th_percentile": 934.09, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 457.7, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 309.72, "10th_percentile": 309.72, "90th_percentile": 309.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 522.16, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 522.16, "10th_percentile": 522.16, "90th_percentile": 522.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA NM EMPLOYEES", "standard_charge_dollar": 152.26, "standard_charge_percentage": 16.3, "standard_charge_algorithm": "All Services; 16.3% Billed", "median_amount": 152.26, "10th_percentile": 152.26, "90th_percentile": 152.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 16.3% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "DCH COMPSYCH", "standard_charge_dollar": 747.27, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEF; 80% Billed", "median_amount": 747.27, "10th_percentile": 747.27, "90th_percentile": 747.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 747.27, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 747.27, "10th_percentile": 747.27, "90th_percentile": 747.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA ALTERNATIVE", "standard_charge_dollar": 203.63, "standard_charge_percentage": 21.8, "standard_charge_algorithm": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 203.63, "10th_percentile": 203.63, "90th_percentile": 203.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 168.14, "standard_charge_percentage": 18.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 168.14, "10th_percentile": 168.14, "90th_percentile": 168.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 18% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH BEACON HEALTH OPTIONS BHS", "standard_charge_dollar": 467.05, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 467.05, "10th_percentile": 467.05, "90th_percentile": 467.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA ASA", "standard_charge_dollar": 634.25, "standard_charge_percentage": 67.9, "standard_charge_algorithm": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 634.25, "10th_percentile": 634.25, "90th_percentile": 634.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 67.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 217.64, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 217.64, "10th_percentile": 217.64, "90th_percentile": 217.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS PPO", "standard_charge_dollar": 217.64, "standard_charge_percentage": 23.3, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed", "median_amount": 217.64, "10th_percentile": 217.64, "90th_percentile": 217.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 23.3% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "DCH BEECH STREET/CAPP CARE", "standard_charge_dollar": 840.68, "standard_charge_percentage": 90.0, "standard_charge_algorithm": "ALL SERVICES; 90% Billed", "median_amount": 840.68, "10th_percentile": 840.68, "90th_percentile": 840.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL SERVICES; 90% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 139.18, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 139.18, "10th_percentile": 139.18, "90th_percentile": 139.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 139.18, "standard_charge_percentage": 14.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 139.18, "10th_percentile": 139.18, "90th_percentile": 139.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 14.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 651.25, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 651.25, "10th_percentile": 651.25, "90th_percentile": 651.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "DCH BCBS HMO", "standard_charge_dollar": 651.25, "standard_charge_percentage": 69.72, "standard_charge_algorithm": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 651.25, "10th_percentile": 651.25, "90th_percentile": 651.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 69.72% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "DCH AETNA", "standard_charge_dollar": 579.14, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 579.14, "10th_percentile": 579.14, "90th_percentile": 579.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH AETNA", "standard_charge_dollar": 579.14, "standard_charge_percentage": 62.0, "standard_charge_algorithm": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 579.14, "10th_percentile": 579.14, "90th_percentile": 579.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 62% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $934.09 @ 6.8% = $63.52 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": 63.52, "10th_percentile": 63.52, "90th_percentile": 63.52, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $934.09 @ 6.8% = $63.52 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": "BLUE CROSS MEDICAID [1612]", "plan_name": "DCH ILLINOIS MEDICAID", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $934.09 @ 6.8% = $63.52 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": 63.52, "10th_percentile": 63.52, "90th_percentile": 63.52, "count": "0", "methodology": "other", "additional_payer_notes": "APGs; 100% Billed, and; Pricing Extension - DCH HB XR MULT PRICE 3M $0 RETURN & HAS APG FOR DCH; Note: Multiple pricing methods applied. Percent of APG: $0.00 @ 100% = $0.00. Percent of Claim Billed: $934.09 @ 6.8% = $63.52 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 BLUE CROSS MEDICARE ADV [2304]", "plan_name": "DCH BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 934.09, "10th_percentile": 934.09, "90th_percentile": 934.09, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "DCH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 934.09, "10th_percentile": 934.09, "90th_percentile": 934.09, "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": "DCH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 934.09, "10th_percentile": 934.09, "90th_percentile": 934.09, "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": "DCH ADVOCATE IPA", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 934.09, "10th_percentile": 934.09, "90th_percentile": 934.09, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "CATH ANGIO GUID JL3.5 HEARTRAIL III 6FRX100CM", "code_information": [ { "code": "SUP-147952", "type": "CDM" }, { "code": "C1887", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 139.18, "maximum": 934.09, "setting": "outpatient", "gross_charge": 934.09, "discounted_cash": 653.86, "payers_information": [ { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "DCH CIGNA BROAD", "standard_charge_dollar": 457.7, "standard_charge_percentage": 49.0, "standard_charge_algorithm": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 309.72, "10th_percentile": 309.72, "90th_percentile": 309.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "DCH SEIU HEALTHLINK", "standard_charge_dollar": 588.48, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 588.48, "10th_percentile": 588.48, "90th_percentile": 588.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "DCH NON-CONTRACTED PAYORS", "standard_charge_dollar": 934.09, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 934.09, "10th_percentile": 934.09, "90th_percentile": 934.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "DCH UHC CORE", "standard_charge_dollar": 442.76, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 442.76, "10th_percentile": 442.76, "90th_percentile": 442.76, "count": "0", "me